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New Facility <br />Sil <br />State CAAPN <br /> Consultation ^Change of Owner Repairs or Remodel Other <br />I iNuor <br /> Facility Owner <br /> Billing Party Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />Address <br />State '2,P <br />Phone <br /> Facility Owner 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 <br />Address City State <br />Phone Phone Email <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property <br />/ PROPERTY / BUSINESS OWNER OPERATOR / MANAGER <br />Rev 07/10/2024 <br />If mobile food truck <br />'pumper truck <br /> Application for <br />Operating Permit <br />SA <br />Existing Facility <br />City.' <br />> y ? IZZtf A) <br /> Facility Contact <br />Type of Service <br />Requested <br />Comments <br />5^^on <br />PE <br /> Check# <br />Contact Types F Billing Party <br />required <br /> Facility Owner <br />Ph°ne <br /> Billing Party <br />FAqxixowsM <br />Record Number <br />5Rasp1070 <br />Payment <br />Received By <br />■ form. <br />I also certify that I have prepared this application and tl <br />Standards, SI ATE and FEDERAL laws. <br />APPLICANTS SIGNATURE: " /*------------------------------ <br /> OTHER AUTHORIZED AGENT _________________ <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />Itl^se RELEp SE INFORMATION: Whe" applicable, I, the owner or operator of the property located at the above site address, hereby authorize the <br />DEPARTMENT as snnn is geO. e^n,Ca' data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />--------------------T as soon as 11 s ava|lable and at the same time it is provided to me or my representative. <br />^Accepted By ~ <br />VidaS P. <br />•Date ' . <br />>ash. <br />Assigned To <br />Fee <br />____S .^0 <br />San Joaquin County Environmental Health Department <br />_________Application Form <br />_ ~~F3c(y^=> Ctova -cz, <br />Ca i < j;/ <br />"Supervisor District <br />If contractor, indicate type^^rUirense number <br />to be performed will be done in accordance with all SAN JOAQllIN COUm^hdh^rnl^Qodes. <br />--------------------------— DATE: -5" / 7/ 2^^ <br />____P Yjs 51/3(035 93__________ <br />”□ Facility Contact , I □ Property Owner I □ Contractor I ^Architect <br />J I I__