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❑ New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Namg <br /> 0 ,,7 f PC)nV4S <br /> Site Address CI State ZIP <br /> Sow `It?Se.INr1+e- .�vv,--- � �� «, C.A q1; > 5 6 <br /> APN Supervisor District <br /> Type of Service El Application for ❑Consultation Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number ViN <br /> pumper truck <br /> Contact Types C7 Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <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 Ci y ' ✓'y State ZIP <br /> 15 2$y er, nArC-t Te-rt` 14 S 33[) <br /> Phone Phone Email <br /> 6 �t 2V ZS 9 . Lf^`1 k'euln <br /> ❑Billing Party ❑Facility Owner 0 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 A <br /> IL <br /> ❑Silting Party ❑Facility Owner ❑Facility Contact 0 Property Owner ❑Contractor <br /> First Name Last name If cont��Nor,indict4zK, Q�nse number <br /> „rD J <br /> Address City SLateN OROOV �uNry <br /> N )A I <br /> Phone Phone Email Thii,r <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 la / ,21 2 2 S <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 r( Assigned To Linked FA ID <br /> Date PE Fee Record Number <br /> -�a a� a5 1 0AIX <br /> 2 �� Payment <br /> ❑Cash C3 Check B Confirmation# Received By <br /> Rev07/10/2024 <br />