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z^c^yx-vp- C>Oc'-tSAk^J New Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />CitySite Address aState ZIPLodi <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 numberLast name <br />Address State 6k ZIP WHO <br />'hone Phone Email <br /> 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 <br />First Name Last name <br />Address City State <br />Phone Phone Email <br /> PROPERTY / BUSINESS OWNER OTHER AUTHORIZED AGENT <br />Title <br />Linked PAIDAccepted By Assigned To <br />PE FeeDateW3 <br /> Check It Confirmation ti <br />Rev 07/10/2024 ?R 0)6 22- <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <br />Type of Service <br />Requested <br />Comments <br />jJ/cash <br />Application Form <br />l‘bl\ “Wk SVi&eV-_______ <br />Supervisor District <br />r <br /> Existing Facility <br />11^ <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 />Record Number <br />Payment / A. <br />Received Byf J <br /> Architect <br />If contractor, indicate type and ■ <br />zip <br />09 ?025 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge thaTarFsJwf <br />specific ENVIRONMENTAL HEALTH DEPAR7MENT hourly charges associated with this project or activity will be billed to me or my business as identi?ie?lM*TMf£JYy. <br />form. <br />I also certify that I have prepared this application andtfiat the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. ~7 / / 2 <br />APPLICANT’S SIGNATURE:./ vll\J DATE: 1 ! ll <br />T OPERATOR/MANAGER <br />Name_______________ <br />dzi to stwi- <br /> Billing Party