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[Xf New Facility □ Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />J <br />APN <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />License Plate Number VIN <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license number <br />State <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address City State ZIP <br />Phone Phone Email <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner <br />First Name Last name <br />Address City 10 <br />EmailPhonePhone <br />formed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />DATE: <br />□ PROPERTY / BUSINESS OWNER □ OPERATOR/MANAGER <br />Title <br />Linked FA ID <br />□ Confirmation tt□ Check # <br />7 <br />□ OTHER AUTHORIZED AGENT <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 />Contact Types <br />required <br />Email <br />Site Address <br />Supervisor District <br />ZIP <br />Record Number <br />ZIPState <br />Type of Service <br />Requested <br />Comments <br />□ Application for <br />Operating Permit <br />If mobile food truck or <br />pumper truck <br />City <br />^>1 ID I 3^' <br />City <br />AcceptTff c. <br />Rev 07/10/2024 <br />Assigned To q <br />Ltlcfo \O • <br />Fee J <br />3n2-<2><z> <br />Last namp <br />State <br />_______________________________________________ — <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledgeSnMfiy^jle 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 <br />\ /Standards, STATE and FEDERAL laws^-n/^Z-------''b*' <br />X APPLICANT'S SIGNATURE: ---------- <br />□ Contractor <br />If contractoEj^y^^^nse number <br />I Vp <br />First Name <br />_________________ <br />.Address <br />Phone Phone 7 <br />pe\(p(D3 <br />Payment zy / <br />Received By / /