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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> r Application Form <br /> Facility ame <br /> � L5 l 7 <br /> Site Address Ci State ZIP <br /> a � �� 7 <br /> APN Sup i r District <br /> Type of Service pplication for ❑Consultation CJ Change of Owner Q Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate 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 Name �. Last name If contractor,indicate type and license number <br /> _)Si <br /> Add ess , �ity State, 21� __ <br /> MPhone PhoAe Lmail <br /> ❑Billing Party ❑Facility Owner C7 Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and lit ense number <br /> Address City State ZI <br /> Phone Phone Email J4* <br /> ^^1I''9y <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor y <br /> �71jWoNM-6 <br /> First Name Last name if contractor,indicate type and lic Her <br /> T <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 application and that the work to be performed will be done in accordance with all SAN JOAAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and <br /> APPLICANT'S SIGNATURE: s. <br /> L la DATE: $ <br /> -PROPERTY/BUSINESS OWNER OPERATOR/MANAGER 0 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,hereby authorize the <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> Accepted A ed Tof I� Linked FA ID <br /> Date PE f} .� Foe Record Number <br /> �/ � Payment <br /> ❑Cash Check# f f ❑Confirmation H Received By <br /> Rev 47/14/2424 <br /> W 11 w=w <br />