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San Joaquin County Environmental Health Department <br />Application Form <br /> Change of Owner Repairs or Remodel Other Consultation <br />"tZ I <br />VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />/d'Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />A Ao AI o <br />5^ <br /> Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />State ZIPAddressCity <br />Phone Phone Email <br /> Property Owner Contractor Billing Party Facility Owner Facility Contact <br />First Name Last name <br />State ZIP.Address City <br />Phone Phone Email <br />DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR / MANAGER PROPERTY / BUSINESS OWNER <br />Title <br />Linked PAID <br />Contact Types <br />required <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 />If mobile food truck or <br />pumper truck <br />Email <br />:ion and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />ZIP <br />ZIP <br />Record Number <br /> New Facility Existing Facility <br />state <br />ck^orx <br />Type of Service <br />Requested <br />Comments <br /> Application for <br />Operating Permit <br />License Plate Number <br />- VRA <br />Supervisor District <br />-------- <br />State <br />r A <br />Last name <br />IA<_4 tfXSMvAc <br />City <br />Facility Name <br />APN <br />rv><J'AciC <br />Phone <br />Date | <br />Rev 06/12/2024 <br />Accepted By <br />P>OI <br />First Name <br />Address <br />Phone. <br />Billing Party <br />If contractor, indicate type and license number * <br />-------- <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 apj <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE:G