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❑ New Facility 'isting <br /> Facility <br /> (needs SR#) <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Nam ,� ^�/_� �`i,1� <br /> 1 ,x Y-it. �N/ <br /> Site Address , C1 i 1 State <br /> V <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 Plate Number VIN <br /> pumper truck <br /> Contact Types 50 Billing Party 0 Facility O lity.Contact Property Owner It 6ntractor ® Requestor <br /> required <br /> filling Party ❑ Facility Owner ElFacility Contact ❑ Property Owner on ractor ❑Architect <br /> F s Name, Last name If contracto ,IrldIcate type and liven a number <br /> l �.• �1 1 . <br /> A dr ss City State ZI <br /> i �jrf CA-t �vb11,2. <br /> Phone Phone Email 4r�?V •\v' ' <br /> 1 "Z 1 - ' lYi v a , GLh I 1/ 6-blk <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 If 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 the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards, STATE and FEDE L la r y) <br /> en <br /> APPLICANT'S SIGNATURE: f C �!� _ DATE: <br /> ❑ PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGERIOT HER AUTHORIZED AGENTT2 r+ �� _- I 0100► f ' AA <br /> MEIf APPLICANT is not the BILLING PARTY, proof of authorization to sign is required RR/� Nr <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, I, the owner or operator of the property located at the above site address, hereby author izEthe 1v <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH b <br /> DEPARTMENT as soon as it is available and at the same time it Is provided to me or my representative. <br /> Accepted B Ns Assigned , Linked FA ID JOAQ�� �015 <br /> lV 1 y <br /> Datel' ��/n/� Fee pp❑Cash � IV <br /> : Record Nurnbpr TlI SEA F � ]Y <br /> I I t - Payment , II I i— N7 <br /> ❑Check# �Confirmatlo n# l7CT Received By (�J <br /> Rev 07/10/2024 2 of 6 <br />