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❑ New Facility Existing Facility <br /> (needs SR#) <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Nve <br /> 51te Address � � _ t..� h State� ZIP <br /> 1 , <br /> APN Supervisor Dist ict <br /> Type of Service ❑ Application for ❑Consultation ❑Change of Owner ❑ Repairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> CommenA si � <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types 60 Billing Party ❑ Facility Owner IN Facility Contact ❑ Property Owner M Contractor ® Requestor <br /> required <br /> Willing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner oatractor ❑Architect <br /> First N f If contracto , ndicate type and license number <br /> yn <br /> Address City State ZIPr, <br /> I o e mail <br /> �UZ3 t t Phone E,Y��� t( 1 . • ` � <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 Parry ❑ Facility Owner ❑Facility Contact ❑ Property Owner ❑Contractor ❑Architect <br /> First Name Last name 7 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 t ' apl#cation and that the work to be performed will be done In accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDE AL la /�k <br /> APPLICANT'sSIGNATURE: ATE: 1 LCJL <br /> nil <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 /> Accepted Blft u/ �� Assigned A To f I � �l 04Record <br /> Linked <br /> �m�1 y 9 2- <br /> Date <br /> PE Fg Number <br /> ❑Cash ❑Check» ❑Confirmation# yment <br /> Received By <br /> Rev 07/10/2024 2 of 6 <br />