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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> FacilitK Name <br /> l vu 7/iL tale C --K , " <br /> Site Tess City State <br /> A <br /> c� 1 • S"rr ►v <br /> APN Supervisor District IF <br /> Type of Service gApplication for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested bperating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck L Z. <br /> Contact Types ❑Billing Party ❑facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> filling Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> Fi st Name La name If contractor,indicate type and license number <br /> Ce- , /`1 , t �t�L t{ <br /> Address City State ZIP <br /> 4o l ( i ---7 D11.( <br /> Phone Phone Ail <br /> 0efi-WS-0z.3 1 r3 11 <br /> ❑Biding 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 Phvne Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor PAY4 <br /> ❑Architect <br /> First Name Last name if contractor, e[ 6e number <br /> Address City State MAY 12 11P <br /> Phone Phone Email CAN E►IMRQui uMrr <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge Wd/or project <br /> spet:ffic 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 /> 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. _ I ] <br /> APPLICANT'S SIGNATURE: �5 DATE: ` 2- » `U,:_S <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 PE Fee Record Number <br /> 05//2_lZ5 /&03 /7 Z . mm /}PZS(7)2 03m <br /> ❑Cash ❑Check p Confirmation q Payment <br /> v ��wvv Received By <br /> Rev 07/10/2024 <br /> ��2Sc�S2. <br />