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❑ New Facility Existin Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address Ci State ZIP <br /> AD c <br /> APN Supervisor District <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner epairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> required <br /> Billing Party �Q Facility Owner 'facility Contact roperty Owner ❑ Contractor ❑ Architect <br /> Q Jl �r <br /> First Name Last r?me If contractor, indicate type and license number <br /> `�41YV VA <br /> Address �� `�Q� � / City State ZIP <br /> ,wu A, ! C a('4 <br /> Phone y Phone Email 16 3 '3 / 0- <br /> 0 Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ontractor ❑ Architect <br /> First Name Last ame If contractor, indicate typed lice se .number <br /> cot) 3u 1 a Lr <br /> Address City State �\A ZIP r , <br /> vx <br /> Phone Phone jUEmail <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> A <br /> First Name Last name If contractor, indicate type and licens �r <br /> T <br /> Address City State ZIP A n % O <br /> Phone Phone Email 4/V /' <br /> FNV qQV <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and 4( TY <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on thi ME T <br /> form. <br /> I also certify that I have prepared this appli ion and t t th k to be performed will be done in accordance with allSA�1�JJOAQUIN COUNTY Ordinance Codes, <br /> Standards, STATE and FEDERAL laws. 3I <br /> APPLICANT'S SIGNATURE: DATE: <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 /> Acce t d B As ed o Linked FA ID <br /> 7a_ c �' t0 210-1 <br /> Date kPE Fee Record NumberC72❑ Cash Check# Confirmation # � �� Payment <br /> Received By <br /> Rev 07/10/2024 <br />