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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />•’Facility Name <br />State a* <br /> Consultation Change of Owner Repairs or Remodel Other <br />License Plate Number VIN <br /> Facility Owner Facility Contact Property Owner Contractor Architect Billing Party <br />^-Billing Party Property Owner Architect Facility Owner Facility Contact Contractor <br />If contractor, indicate type and license numberLa; <br />State ZIPC'r <br /> Property Owner Contractor Architect Facility Contact Facility Owner <br />If contractor, indicate type and license numberLast nameFirst Name <br />City State ZIPAddress <br />Phone EmailPhone <br /> Property Owner Contractor Architect Facility Contact Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPCityStateAddress <br />EmailPhonePhone <br />A DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGERR <br />Title <br />Linked FA IDAssigned To <br />Fee <br /> Check tt <br />Rev 07/10/2024 ItonO-fyisy <br />Contact Types <br />required <br /> Application for <br />Operating Permit <br />If mobile food truck or <br />pumper truck <br />Type of Service <br />Requested <br />Comments <br />Ina <br />[^Confirmation # <br /> Application Form <br />Supervisor District <br />Phone\ <br />Z UQO <br />/ <br /> Billing Party <br />by authorize the <br />w <br />I ^First Name <br />7“ <br />Record Number , ./4Pa40Qgll <br />-Site Address <br />APN <br />Accepted By<~^ <br />PE 1(p02 <br />'ork to be performed will be done in accordance with all SAN JOAQUIN COUfj^/Ordinance Codes, <br />„ JtJl-30 ° <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 silea^t’ <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNT <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> Cash <br />name — <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 application and that <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: ___ <br /> PROPERTY / BUSINESS O’ <br />Address / <br />3 <br />Phone