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❑ New Facility VExisting Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form Yk 0� V2-Le I) <br /> Facility Name <br /> Site Address � �` � �/� City State ,. l ZIP ?�Olz�a <br /> APN Supervisor District <br /> Type of Service Application far ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumpertruck <br /> Contact Types ❑Billing Party KFacilityOwner ❑Facility Contact ❑Property Owner 0 Contractor ❑Architect <br /> required <br /> Billing Party Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name .7- f�;� *df Last name n If contractor,indicate type and license number <br /> Address ra� City �� _J State ZIP /L7w7 <br /> PO, ,,,, Phone Email _ 1��� •�� <br /> ❑Billing Party ❑Facility Owner ❑Facility y Contact L1 Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,Indicate type and license number <br /> Address City State ZI P <br /> Phone Phone Email <br /> ❑Billing Party ❑FacilityOwner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address city State ZI P <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 /> farm. d <br /> (also certify that I have prepared this a ati and at the work to be performed will be done in accordance with all SAN OAQUIN COUNTY O jn3rtt� <br /> Standards,STATE and FEDERAL law <br /> ` 2 C' <br /> APPLICANT'S SIGNATURE: DATE:/PROPERTY/BUSINESS OWNER 0 OPER OR/MANAGER ❑OTHER AUTHORIZED AGENT IF 4UG0 ' Vie. <br /> Title L <br /> 2021 <br /> It APPLICANT is not the BILLING PARTY,proof of aut orization to sign is required JflaQLlJN <br /> AUTHORIZATION TO RELEASE INFORMATION:when applicable,1,the owner or operator of the property located at the above site addrek C �JNAY <br /> ON <br /> release of any and ail results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRME L AC <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. N <br /> Accepted ByV Assigned To �, •� n Linked FA SD�'/1 /1/S /, / <br /> Date PE Fee �i1L/�J� G Record Num7Jber,�! �'�U v <br /> 1 7 - /7r a� -SR2ga)0352- <br /> Rev 06/12/2024 �' y��Lx LX [� ` ��l 1�_q — 0,T) 1 <br />