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Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />Application Form ^0522^^^ <br />State <br />75'37^ <br />APN Supervisor District <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 /> Billing Party Facility Contact Contractor Architect Facility Owner Property Owner <br />R© 5 If contractor, indicate type and license numberLast name <br />CA <br />Email <br /> Architect Property Owner Contractor Billing Party Facility Owner Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />State ZIPCityAddress <br />EmailPhonePhone <br /> Contractor Facility Contact Property Owner Billing Party Facility Owner <br />Last nameFirst Name <br />StateCityAddress <br />EmailPhonePhone <br />DATE: _ <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER <br />Title <br /> Check # Cash <br />Rev 07/10/2024 <br />I <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <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 HEAL! H <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />I—I 3 <br />■eAddressl 2.4T £ {(Th 5} V <br />Date <br />Accepted By <br />Phone <br />9^/0 <br />Type of Service <br />Requested <br />Comments <br />c. <br />PE <br /> Architect <br />If contractor, indicate tyoe andliirjfljtitjiubcr <br /><7^0 <br />___ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my businessSfw^0j*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. , , . /-> r- i r o. i—-APPLICANT'S SIGNATURE: ------------ ---------------------- DATE: O S <br />ZW 733 <br />Linked FA ID <br />Record Number <br />SR2.5<a^c\7 <br />^Confirmation » <br />FirstNaro . <br />Ml igog S\vo)e WftAj <br />Phone <br />Assigned To <br />\<xxd-e cxvAne L. <br />Fee <br />2.