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New Facility □ Existing Facility <br />APN <br />□ Other□ Repairs or Remodel□ Change of Owner^Consultation <br />□ Architect□ Contractor□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party <br />□ Architect□ Contractor□ Property Owner^.Facility ContactFacility Owner[^Billing Party <br />If contractor, indicate type and license number <br />Email <br />□ Architect□ Contractor□ Property Owner□ Facility Contact□ Facility Owner <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPStateCityAddress <br />EmailPhonePhone <br />□ Contractor□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party <br />ImberLast nameFirst Name <br />StateCityAddress <br />EmailPhonePhone <br />DATE: <br />□ OPERATOR/MANAGER □ OTHER AUTHORIZED AGENT <br />Title <br />Linked PAID <br />□ Cash □ Confirmation # <br />Rev 07/10/2024 <br />^2500^35 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <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 HEALIH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />□ Application for <br />Operating Permit <br />Assigned To <br />Vvcx'nCaSCO (2.. <br />VIN <br />Date Record Number <br />APZS 0^233 U <br />License Plate Number <br />23&2AA3 <br />Fee <br />.©CD <br />Type of Service <br />Requested <br />Comments <br />State <br />San Joaquin County Environmental Health Department <br />Application Form <br />Site Address . <br />t-7 Supervisor District <br />Last name <br />ZIP <br />^1^0 <br />First Name <br />—------------------------- <br />Address • <br />Phone ' Phone <br />10^^ <br />□ Billing Party <br />City <br />Accepted By <br />F'vcinc/'.s co ____________ <br />PE <br />____________________________________ <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: ft DATE: T - I r> !L/l L 3 <br />□ PROPERTY / BUSINESS OWNER <br />Payment ft/ <br />Received By I <br />If contractor, indicate typTa’ <br />—<