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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> -T� <br /> "� 3a 1 Po 1.,0 o C o 2 _ <br /> FAPN Supervisor District <br /> Type of Service ❑Application for ❑ ❑� ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑ ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> low a k CA i If contractor,indicate type and license number <br /> N <br /> S i g T v v� �V�- C G S a <br /> Phone <br /> 7a�1 IS <br /> ❑Billing Party ❑Facility Owner ❑Property Owner ❑Contractor ❑Architect <br /> If contractor,indicate type and license number <br /> �e <br /> Phone <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor <br /> T <br /> First Name Last name If contractor,indicate type an n`•• er <br /> Address City State I <br /> Phone Phone Email NEEM DEPARTMENT <br /> EP <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. <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 /1 Assigned To 1 /1� Linked FA ID <br /> Date PE Fee (/1 ReV�1�Arlil�1t <br /> of-a; -a5 -7 aWZOOO <br /> ❑Cash ❑Check ff Confirmation# !� -F �6 Payment <br /> � Receivec1136e- <br /> 11111:�" <br /> Rev 07/10/2024 v i <br />