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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> 7ii <br /> Application Form <br /> FaCillty Name -- COS CC { (q 6W p � 2 <br /> Site Andre 1 -Za 'L S� CityC oc State ZI <br /> T' �c Ga S 5 f <br /> APN Supervisor District <br /> Type of Service 0 Application for xConsultation ❑Change of Owner ❑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 L1 Contractor ❑Architect I <br /> required <br /> ❑Billing Party D Facility Owner ❑Facility Contact ❑Property Owner Q Contractor ❑Architect <br /> First Name 4yl+Deq` Last name If contractor,indicate type and license number <br /> Address ZIP <br /> 3 l © t3 o d.Q(- q S3S C) <br /> Phone Phone Email <br /> ' . 2v <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:1,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 tLspphioncat and that the wo be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL law ` <br /> APPLICANT'S SIGNATURE: DATE: 1-3 <br /> 2� <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/ ANAGER ❑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,here <br /> AUTHORIZATION the �d <br /> release of any and all results,geotechnical data and/or environmental/site assessment Information to the SAN JOAQUIN COUNTY ENVIRONI+ QIJAL HEAI'I hd � ry <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. ?0d <br /> Accepted By Assigned To Linked FA ID lypry4�pq�NPq N <br /> Date 2 PE Fee Record m er <br /> i-3 "f <br /> Payment <br /> U Cash ❑Check 4 ❑Confirmation H Received By <br /> Rev D7/10/2024 <br />