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S New Facility □ Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />City <br />Manteca <br />Supervisor District <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />License Plate Number VIN <br />□ Facility isontact □ Property Owner □ Contractor □ Architect8 Billing Party □ Facility Owner <br />□ Property Owner □ Contractor0 Billing Party □ Facility Owner □ Facility Contact □ Architect <br />If contractor, indicate type and license numberlast name <br />□ Architect□ Property Owner □ Contractor□ Billing Party □ Facility Owner □ Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />ZIPCityStateAddress <br />Phone Phone <br />□ Architect□ Contractor□ Property Owner□ Facility Contact□ Billing Party □ Facility Owner <br />If contractor, indicate type and license numberFirst Name Last name <br />ZIPCityStateAddress <br />EmailPhonePhone <br />.QUIN COUNTY Ordinance Codes, <br />DATE: <br />H OTHER AUTHORIZED AGENT□ OPERATOR / MANAGER□ PROPERTY / BUSINESS OWNER <br />Linked FA It?Assigned ToAccepted By <br />Fee <br />□ Confirmation #□ Check W <br />Rev 07/10/2024 <br />8 Application for <br />Operating Permit <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />Payment <br />Received By <br />First Name <br />San Joaquin County Office of Education <br />Address City <br />Stockton <br />Email <br />sjcoe-ap@sjcoe|net <br />Phone <br />209-468-4834 <br />Record Number <br />AP25023I^- <br />ZIP <br />95213-9030 <br />Type of Service <br />Requested <br />Comments <br />PO Box 213030 <br />Phone <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 />I <br />ZIP <br />95337 <br />State <br />CA <br />□ cash* <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. O <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 COUD-.' 2. -------J <br />Standards, STATE and FEDERAL laws. // - / t / 'I t <br />APPLICANT'S SIGNATURE: //( -------- DATE: -----------/ / / /------------------- <br />Division Director of Operations <br />Title <br />State <br />CA <br />Facility Name <br />_________one. Center <br />Site Address <br />1000 W Center St <br />APN