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H^Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility NameZ <br />/lot A1130 <br />State <br />APN <br />STchange of Owner Consultation Repairs or Remodel Other <br />License Plate Number VIN <br /> Billing Party Facility Contact Property Owner Facility Owner Contractor Architect <br />Billing Party Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberimename <br />Address State j <br />fockJer/n ^20?c'Zl <br /> Contractor Architect Billing Party Facility Owner <br />If contractor, indicate type and license number <br />Address >tate <br /> Property Owner Contractor Architect Facility Contact Billing Party Facility Owner <br />Last nameFirst Name <br />City StateAddress <br />EmailPhonePhone <br /> OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER <br />Assigned ToAccepted By <br /> Check (I Cash <br />Rev 07/10/2024 <br /> Application for <br />Operating Permit <br />If mobile food truck or <br />pumper truck <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 />Contact Types <br />required <br />Phone <br />Date <br />EJFacility Owner <br />Type of Service <br />Requested <br />Comments <br />11O & Q/yjail . wvn <br /> Property Owner <br />City <br />C. <br />PE <br />Title/ <br />Phone <br />Payment ------- <br />Received By^Z^ (J <br />Name <br />L\| cti G- <br />FeeAm __ <br />linked FA ID <br />Record Number <br />e>R.^501 3^^ <br />^Confirmation# <br />If contractor, indicate type and licenfcjQ <br />ZIp <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge^t^jS^Q^j^gQ^ <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as WiQg-p' <br />form <br />I also certify that I have prepared this a^pHratiJin and that thb work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, * <br />Standards, STATE and FEDERAL laws. / jJ // _. . -» — <br />APPLICANT'S SIGNATURE: I DATES? <br />& OPERATOR / MANAGER <br />cbvU Ils <br />S'Tt57' Pacific <br />Supervisor District <br />V^cj'aac <br />(^/facility Contact