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❑ New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name / <br /> Site Address Cit State ZIP <br /> APN Supervisor District <br /> Type of Service pplication for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> e Plate Number VIN <br /> pumper truck If mobile food truck or Licens <br /> Contact Types ❑Billing Party ID Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required I <br /> filling Party ❑Facility Owner ❑Facility Contact ❑Property Owner N.Antractor ❑Architect <br /> First Name Last name If contr ctor,indicate type and license number <br /> 'r► Ala Lctib�" hr�LU LLCM I C, 00 U 2- UO <br /> Adjres` S ` ci!!3L� S State / ZIP����� <br /> 1 t tl-G- 1. <br /> P one Phone Email <br /> Ircyyi <br /> ❑Billing Party acility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> 1-y-WY 'Lt L- ` G. I ci t cam, <br /> Address Cit State <br /> Phone Phone Email <br /> u l Sci L' 11 U5 <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner V Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> V t' gH(r er r( (.. bUU'Z1 -" 00 <br /> Address Cit State ZIP <br /> Phone Phone E ail <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 Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> ❑PROPERTY/BUSINESS OWNER '��OPERALWXNAGER ❑OTHER AUTHORIZED AGENT <br /> Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required r <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 HEALI H <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> Accepted By Assigned To Linked FA ID <br /> Date PE Fee Record Number <br /> Payment <br /> ❑Cash ❑Check q ❑Confirmation N Received By <br /> Rev 07/10/2024 <br />