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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />StateSite Address <br />APN <br /> Other Repairs or Remodel Change of Owner Consultation <br />VIN <br /> Contractor Architect Facility Contact Property Owner Facility Owner Billing Party <br /> Architect Contractor Property Owneracility Owner <br />If contractor, indicate type and license number <br />State <br /> Architect Contractor Property Owner Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPCityStateAddress <br />EmailPhonePhone <br /> Architect Contractor Property Owner Facility Contact Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />State ZIPCityAddress <br />EmailPhonePhone <br />DATE: <br />[^PROPERTY / BUSINESS OWNER OTHER AUTHORIZED AGENT <br />Title <br />Linked FA IDAccepted By <br />FeePE <br /> Check # Cash <br />Rev 07/10/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />Payment <br />Received By <br />Record Number <br />APgSOZ-lSS <br />2.03 210‘S ^3 <br />Type of Service <br />Requested <br />Comments <br />[^Confirmation tt <br />2,2-Zq kJ x <br />Phone <br />Q'’ <br />W&lling Party <br />Address <br />/^Facility Contact <br />Last name <br />2^0^ i m o_______ ________ <br />Supervisor'District <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 />f°rrn- 1I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUN l/i . <br />Standards, STATE and FEDERAL lawy^Z " 7 K <br />APPLICANT'S SIGNATURE: ---------- DATE: <br /> OPERATOR / MANAGER OTHER AUTHORIZED AGENT /) r <br />Sah,” ^025 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required '''OAqhh. <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site^^*VT^^Y^rlQO{(/^l£ <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVlfWlTty1 <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. --------------- <br />ZIPcto a 37 <br />Date <br />©Application for <br />Operating Permit <br />License Plate Number <br /> Facility Contact <br />Assigned To<y>