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`1 New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> k G <br /> Site Address City State ZIP <br /> 2-yy � S 1'1R9a�T W� STuGrr�� 9 zo-F <br /> APN Supervisor District <br /> Type of Service IX Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel 0 Other i <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or L tense Plate Number` VIN <br /> pumper truck U C} (}T i7 1 3 r t v 9(.1Z/3 21VSb y3 i J-3 <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party p Facility Owner 10Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name �'D If contractor,indicate type and license number i <br /> Address � 3 City State ZIP <br /> 6 'e <br /> Phone Phone E all <br /> to 3to66 4 o i-eeA/ps) e-14 M.14 / <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact —7 ❑Property Owner ❑Contractor p.Architect <br /> First Name Last name if contractor,indicate typ CN <br /> 7 <br /> V <br /> Address City State C7 <br /> Phone Phone Email <br /> N E RD UIN Co <br /> ❑Biking Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Arc kr <br /> I <br /> First Name Last name if contractor,indicate type and license number <br /> I <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 JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. til b—" 12 I <br /> APPLICANT'S SIGNATURE: �� 4 DATE: y <br /> ❑PROPERTY/BUSINESS OWNER Q 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,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 availabie and at the same time it is provided to me or my representative. <br /> Accepted By� Assigned T Linked FA ID <br /> C"1r, <br /> Date PE Fee Record a er <br /> i�� $lz. 2-`1 0I3�i-D <br /> Payment <br /> ❑Cash ❑Check fi EC. mation# ea`( Received By <br /> Rev 07/10/2024 <br />