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□ New Facility □ Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />3 74 <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />License Plate Number VIN <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />^Facility Contact0 Billing Party BO Facility Owner □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license numberimi <br />O/ <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor <br />First Name Last name <br />Address City State <br />^NTPhonePhoneEmail <br />irly cl <br />ie w <br />DATE: <br />□ OTHER AUTHORIZED AGENT □ PROPERTY / BUSINESS OWNER >GER <br />Title <br />Linked FA ID <br />PE <br />□ Cash □ Check# <br />Rev 07/10/2024 <br />J <br />t A <br />Phone . TTF <br />1^-70 7^ ^5 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />□ Application for <br />Operating Permit <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 />BILLING ACKNOWLEDGEMENT: I, the undersigned pj <br />specific ENVIRONMENTAL HEALTH DEPARTMENL+tsi <br />form. /f <br />I also certify that I have prepared this application andY] <br />Standards, STATE and FEDERAL laws. ) <br />fflHBHBMBWf E: _______I \ <br />^^Confirmation It <br />Type of Service <br />Requested <br />Comments <br />Record Number <br />|Z)P2.5Q>2 l'S'3 <br />■41 ( W <br />& I Cl J <br />I J <br />APN <br />Accepted By <br />Jeff C. <br />r r^/ Co, i) i <br />Supervisor District <br />Phone <br />iervjl or b isin^ss owner, operator or authorized agent of same, acknowledge that all site and/or project <br />^s associated with this project or activity will be billed to me or my business as identified on this <br />to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />_______________DATE: <br />If contractor, indlcate^ty^e^1 <br />Assigned To <br />Fee <br />nd^P^j^e number <br />:ate <br />El