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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address City State ZIP <br /> 1Co f+ q530H <br /> APN Supervisor District <br /> Type of Service Cl Application for Consultation ❑Change of Owner 1 ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License�Plate Number VfN -�7] <br /> pumper truck 1A TT 2- Z j �� 3 "7 <br /> Contact Types ❑Biking Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Cl Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> Flrst Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> 1L46 SHEARWATE� 9)9 rr� gS363 <br /> Phone Phone Email <br /> ZOgb-7S`� nYAL.0 AA7P A TEEN 1 (.e'm <br /> ©Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State Zip <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name f contractor,Indicate type and license number <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 th ork to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title /b <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,he r <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMEN IAL <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 VV <br /> Date PE Fee � Record Number a 5�y <br /> ❑Cash Check 4 ❑Confirmation 0 Payment <br /> v Received 6y�7 <br /> Rev 07/10/2024 <br />