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□ Existing Facility <br />Application Form <br />Facility Name <br />// / <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />License Plate Number VIN <br />□ Billing Party □ Facility Contact □ Property Owner □ Contractor□ Facility Owner □ Architect <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name c If contractor, indicate type and license number <br />Email <br />□ Property Owner □ Contractor □ Architect□ Facility Owner □ Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City ZIP <br />Phone Phone Email <br />□ Property Owner □ Contractor □ Architect□ Billing Party □ Facility Owner □ Facility Contact <br />First Name Last name <br />Address City State <br />Phone Phone Email <br />DATE: <br />□ OPERATOR/MANAGER □ OTHER AUTHORIZED AGENT □ PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAssigned ToAccepted By <br />FeeDate <br />□ Check #□ Cash <br />Rev 07/10/2024 <br />San Joaquin County Environmental Health Department <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <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 />□ Application for <br />Operating Permit <br />Payment <br />Received By <br />A > 7 <br />PE <br />State <br />State <br />Qu <br />nASupervisor District <br />— <br />State <br />Type of Service <br />Requested <br />Comments <br />f > & <br />Record Number <br />/?P25<2>/625 <br />?025 <br />hr $ <br />Confirmation ff <br />Q ___________ <br />City . <br />Standards, STATE and FEDERAL laws. <1 ( \ , <br />APPLICANT'S SIGNATURE: _______, JCa.-—rfe j\/\-\X <br />New Facility <br />Last name <br />City <br />__________S.SVVno <br />Site Address <br />apn” <br />_______________________________ ____________________________________________ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledtte^£y^jl^^/4fgi/(wW6|ckt <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as 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 withall SAN JOAQUIN COUNTY Ordinance Codes, /-zS <br />C\ Z <br />a U <br />Address / <br />jzA-Z. rU ; <br />.Rhone _. Phone <br />□ Billing Party