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1 � <br /> New Facility ❑ Existing Facility <br /> ` San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility N e <br /> S <br /> Site Ad ess City Sta?0 q � 00 <br /> ZIP <br /> I OV <br /> APN Supervisor District <br /> Type of Service ❑Application for Consultation C7 Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit — <br /> Comments <br /> If mobile toad truck or License Plate Number VIN <br /> if <br /> mbilefoodper truck 2'x$2'-1q3 1�DE�1� 113m� 5c1m� `�2 <br /> Contact Types C ]Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner 13 Contractor L]Architect <br /> required <br /> Billing Party 'f(Facitity Owner Facility Contact ©Property Owner ❑Contractor ❑Architect <br /> First Name Last na a If contractor,indicate type and license number <br /> Addres City State ZIP <br /> Rhone Phone Email <br /> 0 <br /> ❑Billing Party ❑Facility owner C7 Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑ContractorFE l" <br /> First Name Last name If contractor,indicate type a i ���� 11 mber <br /> Address City State c.'. i <br /> P 25 <br /> `"AN <br /> Phone Phone Email H�TM ���nr <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 la sfr � j <br /> APPLICANT'S SIGNATURE: DATE: <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <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 /> Accepted By Assigned To Linked FA ID <br /> FyCJLrC_tSc_a 2' P— <br /> pate PE Fee Record Number <br /> �A I,i1 kto03 1--�G .coo AP250233-1 <br /> Payment <br /> ❑Cash Check tJ ❑Confirmation d Received By <br /> Rev 07/10/2074 ,W 25035 <br />