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W,0535(053 <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address 1 t ` City State ZIP <br /> Vr,.�.. <br /> t"Cxwys <br /> -teCc� R5o <br /> APN Supervisor District <br /> Type of Service JWpplication for •lilliCGnsultation WoChange of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or Lidense Plate Wumber vim <br /> pumper truck <br /> Contact Types ❑Billing Party LX Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required i <br /> ❑Billing Party 0 Facility Owner ❑Facility ContactElProperty Owner 11Contractor ❑Architect <br /> First Name Last nam If contractor,indicate type and license number <br /> ri\Co <br /> Mo , W i v <br /> AddressPO Z DY 7DD� Statg Zf� <br /> Ph nePhone Email 4 C\ <br /> filling Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last ame If contractor,indicate type and license number <br /> Address Ci State ZIP <br /> PO a 3d <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> P <br /> First Name Last name If contractor,indicate type anc p��n <br /> Address City State ZIPS <br /> EP <br /> Phone Phone Email <br /> JOgFQ�UrD�11�y- <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all sil�a3stlf �'r <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified o� n this n1y�m <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 /> APPLICANT'S SIGNATURE: rA' WA) {�DATE: 7 X101 S <br /> F�ROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER CJ❑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 envirunmental/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 <br /> (9tF Assigned To Linked FA ID 00 ^5 <br /> Date IFPE Fee Record Number <br /> 2� 51225mf�2� <br /> � � 8 <br />