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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name W octii j C fU< Dix <br /> eyi J <br /> E <br /> Site Address City State ZIP <br /> tP 2 P1 SLt, �� . GA �l S zc�Z <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 Numb j1 V N �/ <br /> pumper truck � 1'I' SLQ C'j I`l /s Z g jl �� <br /> P ate LO <br /> Contact Types E7 Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Wwcos Last name (� f���f. If contractor,indicate type and license number <br /> Address I i� �l City n' I State <br /> Phon Phone Email <br /> o�-5(ef- -+' q <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 Cmail <br /> ❑Bi{ling Party ❑Facility Owner ❑Facility Contact ❑Properly Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City Stale 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 11 <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.,C/J { 1 <br /> APPLICANT'S SIGNATURE: f4 / 1 c/` �] r t'�_�i DATE: I—Tz ' 2-<;1 P <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT •�Clr `�� <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,her auth�z�tl !6 <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMEf4 H <br /> I <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. MNcrk <br /> 0OP947i IV <br /> Accepted By Assigned To Linked FA ID <br /> FA 0 L) 22 I-C�2- <br /> Date 1 f ?2 - PE l o-� Fee l I� Record N ey <br /> V / o Payment <br /> ❑Cash ❑Check Jf LYConfirmation p f q o�5- Received By <br /> Rev07/10/2024 <br />