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J <br /> Existing FacilityS New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />City <br />Stockton <br />Supervisor District <br /> Other Consultation Change of Owner Repairs or Remodel <br />license Plate Number VIN <br /> Architect Facility Owner Facility Contact Property Owner ContractorB Billing Party <br /> Architect Property Owner Contractor8 Billing Party Facility Owner Facility Contact <br />If contractor, indicate type and license numberLast name <br />ZIP <br />95213-9030 <br /> Contractor Facility Contact Property Owner Billing Party Facility Owner <br />First Name Last name <br />StateCityAddress <br />EmailPhonePhone <br /> Contractor Property Owner Facility Owner Facility Contact Billing Party <br />First Name Last name <br />ZIPStateCityAddress <br />EmailPhonePhone <br />linance Codes,COUNTY <br />DATE: <br />8 OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER <br />Assigned ToAccepted By <br />Fee <br /> Confirmation It Cash <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />8 Application for <br />Operating Permit <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 properly 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 />Email <br />sicoe-ap@sjcoe|net <br />City <br />Stockton <br />Phone <br />209-468-4834 <br />Type of Service <br />Requested <br />Comments <br />NiCK N. <br />0 iTZ <br />First Name <br />San Joaquin County Office of Education <br />Address <br />PO Box 213030 <br />Phone <br />ZIP <br />95210 <br />State <br />CA <br />State <br />CA <br />Record Number / <br />APa50a531 <br />Payment <br />Received By (j <br /> Architect <br />If contractor, indicate type and It <br />Date <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 workAo be performed will be done in accordance with all SAN JOAQUW COU <br />Standards, STATE and FEDERAL laws. / j / -j / /• <br />APPLICANT'S SIGNATURE: ---------------. DATE: __________/yl—/ /^.<,.1- <br />□ operator/manager 8 other authorized agent Division Director of Operations <br />Title <br />If contractor, indicate type and license number <br />Facility Name <br />one. Hammer Lane <br />Site Address <br />1777 E Hammer Ln <br />APN <br />NiCK N <br />P£ IG) 35 <br />^Checks 170^9