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Existing Facility□ New Facility <br />San Joaquin County Environmental Health Department <br />Facil’ty Name ' <br />see Address f cA <br />APN <br />^Change of Owner□ Consultation □ Repairs or Remodel □ Other <br />License Plate Num V'NCPKj,S'5'1/3^33 <br />□ Property Owner □ Architect□ Billing Party □ Facility Owner □ Facility Contact □ Contractor <br />□ Contractor □ Architect□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner <br />If contractor, indicate type and license numberFirst Name <br />StateAddress ZIP <br />□ Billing Party □ Property Owner □ Contractor □ Architect□ Facility Owner <br />If contractor, indicate type and license numberFirst Name Last name <br />State ZIPAddressCity <br />Phone Phone Email <br />□ Contractor □ Architect□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner <br />First Name Last name <br />StateAddressCity <br />EmailPhonePhone <br />7 <br />□ OPERATOR / MANAGER □ OTHER AUTHORIZED AGENT □ PROPERTY / BUSINESS OWNER <br />Title <br />□ Check # <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />□ Application for <br />Operating Permit <br />Payment <br />Received By <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 />^Confirmation ff <br />Type of Service <br />Requested <br />Comments <br />□ Facility Contact <br />Linked FA ID <br />Record Number <br />20 <br />Accepted By <br />Vidofc ______ <br />PE <br />1^0)3 <br />_________Application Form <br />Supervisor District <br />Assigned To <br />FeeDS>eg 1(0(0^25 <br />#ash <br />to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinan <br />36S G _Si_ <br />Phone Emaila <br />If contractor, indicate type|j^i^n^number <br />__________________________________________________________________________ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledgt/^^riLW^ftCg^mjiH <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charge^ssociated with this project or activity will be billed to me or <br />form. <br />I also certify that I have prepared this application and tljatlCe-wark to be performed will be done in accordance with all SAN JOAQUJN COUNTY OrdinanfuModes, <br />Standards, STATE and FEDERAL laws. <br />APPUCANVS SIGNATURE:-------------