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lX Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name u <br />^Xl'Site Address ZIP <br />L-r\Ck <br />APN <br />"^Consultation Change of Owner Repairs or Remodel Other <br />VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />^&-Billing Party ^BFFacility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />State2■o k/ <br /> Contractor Architect Facility Owner <br />If contractor, indicate type and license numberFirst Name Last name <br />StateAddressCity ZIP <br />Phone Phone Email <br /> Contractor Facility Owner Property Owner Architi Billing Party Facility Contact <br />First Name Last name <br />City StateAddress <br />Phone EmailPhone <br /> PROPERTY / BUSINESS OWNER <br />Title <br />Assigned To <br />Fee <br /> Checks <br />Rev 07/10/2024 <br />A <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 />iber <br />Type of Service <br />Requested <br />Comments <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 <br />Standards, STATE and FEDERAL la^r-^7 ft <br />APPLICANT’S SIGNATURE: Z_/ \ / /-DATE: U / <br />C2 v-X< <br />If mobile food truck or <br />pumper truck <br />Phone ‘ , Phone <br /> Billing Party <br />pul <br />m3 <br />Email <br /> Facility Contact <br />.a'First Name <br />Phone n <br />Linked FA ID <br />Record Number <br />Sp.2H(ZXD»42Q) <br />Payment <br />Received By( <br />- State <br /> Application for <br />Operating Permit <br />License Plate Number <br />If contractor, indicate type and li(!^<(/j9'iiHjiber <br />rW1 <br />.-.Last name <br />SAN JOAQUIN COUNTY Ordinance Codes, <br />City, % State <br /> Property Owner <br />Accepted By,-—> <br />PE <br />^Confirmation fi <br /> OPERATOR / MANAGER OTHER AUTHORIZED AGENT <br />L--^ .Wcc'hSupervisor District <br />r2(, <br /> Cash <br />-lp<?4nx