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rl New F;1 iII'v ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> U� Y. <br /> Site Address City State ZIP <br /> w wVe&r 4ve A. <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments ,`, CA��W r <br /> FF <br /> p mobile food truck or `1 iceJr se P a e N b � vIN 1 2 <br /> pumper truck V V <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact Q Property Owner ❑Contractor ❑Architect <br /> First Name Last na a If contractor,indicate type and license number <br /> r v+eZ n <br /> "Addrea City State ZIP <br /> W 1M1Ie G C 4 D <br /> Phone Phone Email <br /> 0 <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact 0 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 i <br /> k I <br /> IQ Billing Party ❑Facility Owner ❑Facility Contact C7 Property Owner ❑Contractor <br /> Orr <br /> First Name Last name If cont indicate indicate t an wise number <br /> �l Jp �J <br /> Address city State �CTH pNM COuNJ'. <br /> AQAj <br /> Phone Phone Email rM�N <br /> r <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned prope or business owner,operator or authorized agent of same,acknowledge that all site and/or project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT ourly arges associated with this project or activity will be billed tome or my business as Identified on this <br /> form. <br /> I also certify that I have prepared this appiicati a e work to be performed will be done in accordance with ail N JOAQUI COUNTY Ordinance Codes, <br /> Standards,STATE and APPLIICANT'SSGNATURE: laws. DATE: <br /> �/t �J,S <br /> ❑PROPERTY/Bu51NE55 OWNER Q 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 1OAQUIN 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 E Fee Record Num5r` — <br /> r �fU�0-t <br /> D ^ ' + ��D cash El Check <br /> Check 47 Confirmation d `P_] t,� <br /> Received By <br /> Rev 07/10/2024 <br />