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0 New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />1-Ck IA d 06 P, I(4 jak IrA kit/ 0, 'b in (k ')G I L.., <br />q TOS ro;P,' k- orkkok illir rS2_ 2 <br />APN Supervisor District <br />Type of Service <br />Requested <br />CI Application for <br />Operating Permit 01:411111111, <br />0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck 4 E ili\-z -7 .6 !Iiii <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />• 0 0 Facility Contact D Property Owner O Contractor CI Architect <br />If contractor, indicate type and license number <br />20q — 466 -- <br />Phone <br />IS --/- 6 <br />1=1Billin g Party 0 Facility Owner I 0 Property Owner CI Contractor 0 Architect <br />r <br />1111111111111 °-)k L— CT) GUL2 e et <br />If contractor, indicate type and license number <br />r. k WO OW ale <br />Phone <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor ENT R cnvimr, <br />First Name Last name If contractor, indicate type <br />State <br />SAN_449AQiiIN <br />NEAL EMPRONMENTAL <br />1:113 <br />ana rri-enweammaoer <br />T2044:5 <br />COUNTy <br />AR NT <br />Address City <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 SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. <br />o PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <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 <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />Title <br />at the above site address, hereby authorize the <br />JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />Accepted By k jog(0‘ Assigned To k.Mck \ A Linked FA ID ..„61. <br />Re <br />00dt49.11 <br />Date PE Fee 000 <br />0 Cash 0 Check # /Confirmation # 1.9v-fiss6--- 761-1- Payment <br />Received B <br />6e7)1 <br />Rev 07/10/2024 <br /> W0%1423