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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Site Address <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 U Architect <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />Email <br /> Architect Billing Party Facility Owner Contractor Property Owner <br />If contractor, indicate type and license numberFirst Name Last name <br />Address StateCity ZIP <br />Phone EmailPhone <br /> Contractor Billing Party Facility Owner Facility Contact Property Owner <br />First Name Last name <br />Address City State <br />2025 <br />Phone EmailPhone <br />DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA ID <br />ReconPEiuoS <br />—1----------------------------------------------- ----------------—----------- <br />J/confirmation # <br /> Cash Check fl <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />£ -I <br />Payment <br />> Received By <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 />Phone <br />? (Xi-670-076 <br />ZIP <br />State <br />Accepted <br />Type of Service <br />Requested <br />Comments <br />7^0 Cd)\FoCO'y; <^4- <br />Supervisor District <br />Last name <br />Al cccza r________ <br />City <br />frfrvh /Mip <br /> Facility Contact <br />Assigned T^^ <br />yZ Application for <br />^Operating Permit <br />Date <br />State . <br />CA <br />Address <br />If contractor, indicate type an/^FTd^igrr^yi- <br />~ D0UN j3 <br />______________________________________________________ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site ancf/CT^M^^y <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: L < <br />First Name <br />Phone