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s <br />L$- Existing Facility□ New Facility <br />Facility Name <br />Site Address <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 />(A <br />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 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 />DATE: <br />PROPERTY / BUSINESS OWNER □ OPERATOR / MANAGER □ OTHER AUTHORIZED AGENT <br />Assigned To Linked FA ID 'Nr <br />PE JIT?.' <br />^Confirmation #□ Cash □ Check # <br />Rev 07/10/2024 <br />Phone <br />If mobile food truck or <br />pumper truck <br />□ Application for <br />Operating Permit <br />Contact Types <br />required <br />San Joaquin County Environmental Health Department <br />Application Form <br />ZIP X- <br />2-2.^ <br />First Name <br />Address <br />State <br />CA <br />Accepted By <br />Date <br />Type of Service <br />Requested <br />Comments <br />Title <br />1 Sarrv <br />/-? g/5~ <f 2 % <br />Supervisor District <br />€4 - co <br />tance Codes, <br />28 <br />authorize the <br />Phone <br />Last name , <br />PA ccr <br />City <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 the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordin; <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <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, teri-by authorize tKe 4 <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENW0kWJ/i <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. ^Or If <br />Woo <br />_Record Number <br />5R9.5<2)1047 / <br />200BtF02>°lO [SUqiW