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❑ New Facility l Existing Facility <br /> O (needs SR#) <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address City State ZIP <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑ Consultation I ❑ Change of Owner ❑ Repairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> Comments _ <br /> If mobile food truck or License Plate Number VIN <br /> pumpertruck <br /> Contact Types W Billing Party ❑Facility Owner IN Facility Contact I ❑ Property Owner M Contractor ® Requester <br /> required <br /> B ,I illing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner otraa/ctor 7 ❑Architect <br /> is d ��Tr 1' I <br /> Fir Larne (��ti , Last rtamp.,I� ,� If contra�c r,indicate type and license number/ <br /> 1ltt//ll�t ( i6 t T l�S ► , C.� 4 t t <br /> Address � � li n city State ZIP�1 <br /> Phone Phone Email /L?�•nt rr�� 'lil. 6 <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 <br /> First Name Last name If contractor, indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <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 /> also certify that I have prepared this ar aticlf and that the work to br performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and ER laws. <br /> APPLICANT'S S GATURE N f/ J! DATE: <br /> ❑ PROPERTY/BUSINESS OWNER f ❑ OPERATOR OPERATOR/ 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, 1,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 /> Acceptea,�v Assigned Linked FA ID <br /> Date it l ' 2� PE ^lq Fee Record LJum r <br /> (f yt ll i 1. <br /> ❑Cash ❑Check# ❑Confirmation# ay <br /> Received By <br /> Rev 07/10/2024 2 of 6 ����(D 1 -7 <br /> 1 <br />