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X New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address I City State ZIP P <br /> 0 o, f [ 2- <br /> A N Supervisor Distri t <br /> Type of Service XApplication for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments Plan Review �bY M 1' <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required 1. <br /> Billing Party Facility Owner Facility Contact Q Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> k Oar <br /> Address —� tG Ciwicy State ZIP <br /> Phon V 1 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 Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type a i e er <br /> Address City State JP �D <br /> Phone Phone Email (f 10 <br /> F °�aQ� 0,?4 <br /> IA,- <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that aIT"P1W'Pi6jrct <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identiwy7.this <br /> form. <br /> I also certify that I have prepared this ap lication 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. f <br /> APPLICANT'S SIGNATURE: DATE: <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 By Assigned To Linked FA ID <br /> Date l t5 ZC172 PE Fee Record Number <br /> RJD7(4 -I- <br /> sl�,a� 17¢7G1077 <br />