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X New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name 1 <br /> Site Address City State ZIP <br /> 1-01 5 V \L)Y c 'et �iSZ�b <br /> APN Supervisor District <br /> Type of Service X Application for ❑Consultation CJ Change of Owner Q Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> /)a,) MFF <br /> If mobile food truck or Eicense Plate Number VIN �7 <br /> pumper truck L ��h H I ] I L411—1m 9 16 Zn rt I 2 H(o 0 <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> JN Billing Party Facility Owner Facility Comact ❑Property Owner ❑Contractor Q Architect <br /> First Name Last name If contractor,Indicate type and license number <br /> I'l 11 t�. (')\(A i- <br /> AddressCity State ZIP <br /> q�( �ilva`i o�U f Jc ULt o <br /> Phone Phone Email <br /> r sa ytAvttl�l`� c o'M <br /> ❑Billing party ❑Facility Owner C7 Facility Contact—75-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 /> 0 Billing Party ❑Facility Owner ❑Faculty 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 prepared this ap 'cation and that the work to be performed will be done In accordance with all SAN JOAUUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. --i u l <br /> APPLICANT'SSIGNATURE: LATE: U V <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign is required ,, <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hetewptyciq,e than <br /> retease of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENViR2 TAL Hle.AidH aZ} <br /> DEPARTMENT as soon as it is available and at the same time It is provided to me or my representative. �'�CT <br /> Accepted By Assigned To Linked FA ID <br /> Vi dd R Mdelcla r t L <br /> Date PE Fee + Record Number <br /> ({IP, 7-12d24 1+cm3 R2.(Da OP24008 <br /> Payment <br /> ❑Cash [3 Check a eConfirmation s Recelvetl By <br /> Rev 07/10/2024 <br />