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] New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address 20 � �GG � �� City t OnU r State ZIP <br /> (' 1 0 <br /> APN @ Supervisor District <br /> Type of Service Application for I]Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments � d <br /> If mobile food truck or License Plate Number , 1��.t�j �� AXIACIUMCN6136 <br /> pumper truck `-rJ Jl � <br /> Contact Types ❑Billing Party ©Facility Owner ❑Facility Contact ❑Property Owner C]Contractor ❑Architect <br /> required <br /> 'ifZBilling Party acifity Owner Facifity Contact lDkproperty Owner ❑Contractor ❑Architect <br /> First Nam Last name If contractor,indicate type and license number <br /> Address (SJf{ ,r�51 ay�GY � M City pC/ly ion State C A ZIP <br /> Phone 1 Phone Email <br /> SaoYe ^/ as c a rY• <br /> E7 Billing Party ❑Facility Owner ❑Facifity Contact ❑Property Owner ❑Contractor p Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> D Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor /AA. <br /> first Name Last name If contractor indicat and li II er <br /> 0 <br /> Address City State At, F qQ ZI O`S <br /> R <br /> Phone Phone Email OFp.QF�T(�NIlk <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site McIlor project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified an this <br /> form. <br /> I also certify that I have prepared this application n that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. 7 <br /> • APPLICANn SIGNATURE: DATE: ,! <br /> ❑PROPERTY/BUSINESS OWN ❑OPERATOR/MANAGER U OTHER AUTHORIZED AGENT <br /> Title <br /> VAPPLICANT 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 1 Assigned To _ Linked FA ID <br /> • u <br /> pate PE Fee Record Number <br /> 1 1 337_ Ap 2-5CD I <br /> K <br /> IF Payment <br /> ash ❑Check tl ❑Confirmation g Received B _. <br /> Rev 07/10/2024 <br />