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❑ New Facility * Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> 1- <br /> G v� _ <br /> Side Address City �y State ZIP <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑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 /> pumper truck 3 <br /> Contact Types ❑Bifling Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> C7 Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> FirstName Las me r If contractor,indicate type and license number <br /> Address /f- CI y // State ZIP <br /> TGr 2 2 <br /> Phone Phone Email <br /> C <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> A <br /> Address City State Zip r^�f <br /> Phone Phone Email Jq pt 13 2025 <br /> ElBilling Party El Facility Owner ❑Facility Contact ❑Property Owner ElContractor ItqN COUNTY <br /> TH <br /> First Name Last name If contractor,indicate type and Llicense nM'iYt m8w. <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 S N JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL law . <br /> APPLICANT'S SIGNATURE: : C/ 4aZDATE: I13 1-7 <br /> ❑PROPERTY/BUSINESS OWNER ❑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 available and at the same time It is provided to me or my representative. <br /> Accepted By Assigned To Linked FA ID <br /> Date I I PE Fee Record Number <br /> Payment <br /> card <br /> a +-� b ❑Check# ❑Confirmation# Received By <br /> Rev 07/10/2024 1 62(40GC <br />