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f(2. <br />KKExisting Facility□ New Facility <br />state ca <br />APN <br />□ Consultation "H Change of Chvner □ Repairs ot Remodel □ Other <br />license Plate Number VIN <br />□ Billing P.irty Q Facility Owner 0 Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license number <br />J <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name last name If contractor, indicate type and license number <br />Address City State ZIP <br />Plsone Plionc Email <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor <br />First Name last name If contractor, indicate type and lici <br />Address City SUte <br />Plx.»ne Phone Email <br />DATE: <br />□ OPERAFOR / MANAGER □ OTHER AUTHORIZED AGf NT <br />Title <br />si□ <br />Rev 07/10/202*1 <br />If mobile lood truck or <br />pumper truck <br />□ Application for <br />Operating Permit <br />Type of Service <br />Requested <br />Comments <br />Email <br />$ jVd-c c />A . h <br />San Joaquin County Environmental Health Department <br />Application Form <br />T zip <br />^5 <br />j z <br />| ZIP <br />□ Architec P4YI <br />■J3 PROPLAIY / BUSINESS OWNFR <br />ZIP - <br />nt <br />ED <br />JUL 2 2025 <br /> ' 1------- <br />Bill ING ACKNOWLEDGEMENT: I. the undersigned property or business owner, operator or authorized agent of same, acknowledge that <br />specific ENVIRONMENTAL HEALTH DEPARTME NT liourly charges associated with thrs project ex activity will be billed to me or my business as identified ornSP^»' <br />• : . ~ - <br />to® <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign t$ requited <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, geotec finical data and/or environmcntal/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAl IH <br />DEPARTME NT as soon as it is available and at the same time it rs provided to me or my representative <br />State <br />kA <br />MB <br />first Name <br />Address <br />Pt»ne I Phone <br />1 vis__________ <br />^Yac^' <br />~~~ <br />£ <br />.ot District <br />Facility Name . . <br />_____r\ <br />Site Address <br />Supervise <br />form. <br />I also certify that I hove 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 Ef DFRAl laws, r '7’ ( A /7 I / -- <br />APPLICANTS SIGNATURE: | --------- DATE: O Jl-| 9 -^Z f 4>/ 'S <br />Last name <br />Aj’t y1 _______ <br />City P