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❑ New Facility Existing Facility <br /> (needs SR#) <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address -' �rG1[ w�,VGL -�- - -- '— city State ZIP_ ��� <br /> APN L Supervisor D ct <br /> a1 4 - 18 - _ <br /> Type of Service ❑Application for ❑ Consultation ❑ Change of Owner ❑ Repairs or Remodel _ P<ther <br /> Requested n NrOpperating Permit !' n n� �R.�. 1 <br /> Comments15)c c�, 1!ky 14U NIP f W Co��IQ �l T Fr�cG� <br /> --F <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types W Billing Party ❑ Facility Owner ® Facility Contact ❑ Property Owner ® Contractor ® Requester <br /> required <br /> Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner Co ractor ❑ Architect <br /> First Na a Y` n�_ Last name If contrac or, indicate type and license number <br /> Address D a l i V)'n Ro C'ty Stat� ZI r45ti12 <br /> Phone Phone Y t c 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 O <br /> First Name Last name If contractor, <br /> tinn t and lice se r <br /> Address City State �9`TVgQ O <br /> F,yr viy�Y <br /> Phone Phone Email .,ft <br /> T <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 this application 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: ��12 <br /> ❑ PROPERTY/BUSINESS OWNER ❑ OPERATOR/ MANAGER XJ 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 8y �� Assigned'so � t Linked FA ID <br /> � , <br /> Date/D PE�'7 FeZt/� I Record Number <br /> v/ 1161 S a 5 R 5 to <br /> ❑Cash ❑Check Ifonfirmation k Payment <br /> /� Received By <br /> Rev 07/10/2024 2 of 6 <br />