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T <br />State ZIP ^5336 <br />APN <br />□ Repairs or Remodel □ Other□ Change of Owner <br />License Plate Number VIN <br />^Facility Owner S-Facility Contact □ Contractor □ ArchitectBLProperly Owner"H-Billing Party <br />□ Architect□ Property Owner □ Contractor□ Facility Contact□ Billing Party □ Facility Owner <br />If contractor, indicate type and license numberLast n.ami <br />State C4 <br />D <br />□ Architect□ Contractor□ Property Owner□ Facility ContactLJ Facility Owner□ Billing Party <br />Last nameFirst Name <br />ZIPStateCityAddress <br />EmailPhonePhone <br />□ Contractor□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party <br />Last nameFirst Name <br />ZIPStateCityAddress <br />EmailPhonePhone <br />DATE: <br />□ OTHER AUTHORIZED tySENT'ROPERTY/ BUSINESS OWNER <br />Title <br />Assigned ToTAccepted By <br />If mobile food truck or <br />pumper truck <br />ContactTypes <br />required <br />□ Application for <br />Operating Permit <br />^^ConsultationType of Service <br />Requested <br />Comments <br />“7 ) <br />€ nt V A-.U l0G^l <br />PE <br />Email <br />Dah/2t/2r <br />If contractor, indicate type and licen <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 />I also certify that I have prepared this jpplifati^^h'd that th^vork to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />If contractor, indicate type and llcerjfi>g|i^^er <br />Ms- <br />Aug - <br />San Joaquin County Environmental Health Department <br />Application Form <br />■Facility Name/x > /I i /-- / <br />SllcAJdfm|4^-7 <br />Supervisor District <br />I also certify that I have prepared this applxatiorfahd that thj <br />Standards, STATE and FEDERAL lavy/\/ / <br />APPLICANT'S SIGNATURE: /(^ <br />TfOPERATOP. / MANAGER <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 environmemal/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 />_______________ <br />Phone I Phone <br />linked FA IP