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5JSJ Existing Facility□ New Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address City <br />APN <br />Change of Owner□ Consultation □ Repairs or Remodel □ Other <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />$ Billing Party Facility Owner Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license number <br />Address <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address City State ZIP <br />Phone Phone Email <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address City State ZIP <br />Phone Phone Email <br />DATE: r <br />□ PROPERTY / BUSINESS OWNER □ OPERATOR/MANAGER □ OTHER AUTHORIZED AGENT <br />Title <br />PE inq <m> <br />□ Check H <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 />Phone <br />□ Confirmation tt <br />Type of Service <br />Requested <br />Comments <br />Application Form <br />3 5 5 t) (JjAA <br />Supervisor District <br />Phone <br />Linked PAID <br />Record Number <br />Payment <br />Received By <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 1 have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> DATE: <br />s,atecl4 <br />Assigned To <br />_rron cas co p-- <br />Fee <br />LastnaWX0T^ <br />CitY <br />Email A » <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required C 3 / <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site jxeby authoriwCOj^* <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRfip^ <br />Accepted By <br />JeEP C- <br />Date <br />>y3>\(25 <br />a Cash