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San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Supervisor District <br />Q'fchangeof Owner □ Repairs or Remodel □ Other□ Consultation <br />VINLicense Plate Number <br />□ Architect□ Contractor□ Facility Owner □ Facility Contact □ Property Owner□ Billing Party <br />□ ArchitectG/Facility Owner □ Contractor□ Billing Party □ Facility Contact □ Property Owner <br />If contractor, indicate type and license number <br />□ Architect□ Contractor□ Property Owner□ Facility Owner □ Facility Contact□ Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPStateQtyAddress <br />EmailPhonePhone <br />□ Contractor□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party <br />Last nameFirst Name <br />StateQtyAddress <br />EmailPhonePhone <br />DATE: <br />□ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGER <br />Title <br />Assigned ToAccepted By <br />If mobile food truck or <br />pumper truck <br />□ Application for <br />Operating Permit <br />Contact Types <br />required <br />City ZIP <br />State ZIP <br />Email <br />Type of Service <br />Requested <br />Comments <br />I <br />Address5^ <br />Phone <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 />State <br />First Name \ <br />_________TV<\YY\(X£>____________________ <br />Phone <br />Last name \ <br />Record Number <br />5^-250 \\ 5^ <br />If contractor, indicate type andlR^^^Jr^c^' ’ * <br />p'wL <br />__________________ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on thK^A// <br />form. <br />I also certify that I have prepared this application anj that the work to be performed will be done In accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. <2 z//—7 5/15/2.0 <br />APPLICANT’S SIGNATURE: ___________---------------------------------L----------------------------------------------------- DATE: ---------L-----------------------JZ--------------------- <br />'^'PROPERTY/ BUSINESS OWNER <br />CXli <br />Site Address <br />APN