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❑ New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> L 0 co <br /> Site Address L4 u S d A w�( "I CcyU C� SC P ZIP� J�� <br /> APN Supervisor District J j-� J C. <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> 9L <br /> If mobile food truck or License Ate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Nam Last name If contractor,indicate type and license number <br /> Mc�vy- SJlld,Z"'- <br /> Address City State <br /> q S �gw`S H� SI)c���>, <br /> Phone Phone Email , �u SA')COJQ <br /> 2oa qZL-,j'S ALA M fir.• CUm <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br /> form. <br /> I also certify that I have pre*thniscation and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDEAPPLICANT'S SIGNATURE: DATE: <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT A,gYM <br /> Title H <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required iee <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,I�y authorelease of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVI�0 M L&F ILDEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. 1� �•77 <br /> T- <br /> Accepted By Assigned To II Linked FA ID Oiy CO, <br /> Date PE Fee f _ Record Number . <br /> A f)P amltc1CC> <br /> ❑Cash ❑Check# ❑Confirmation# r� /J��a Payment <br /> 1 V t.r Received�8ry�Rev 07/10/2024 V0,2C5 oo� �l <br />