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San Joaquin County Environmental Health Department <br />Supervisor District <br />□ Other□ Change of Owner □ Repairs or Remodel□ Consultation <br />JI Facility Contact □ Architect□ Property Owner^StBiHing Party B^Fadlity Owner <br />□ Architect□ Contractor□ Property OwnerBilling Party □ Facility Contact□ Facility Owner <br />If contractor, indicate type and license numberLast name <br />rnuiie . _ <br />□ Architect□ Contractor□ Property Owner^Facility Owner □ Facility Contact□ Billing Party <br />If contractor, indicate type and license numberLast name <br />Phone <br />□ Architect□ Contractor□ Property Owner□ Facility Owner□ Billing Party <br />If contractor, indicate type and license number <br />DATE: <br />□ OTHER AUTHORIZED AGENT □ PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAssigned ToAccepted By <br />Record NumberDate <br />□ Confirmation #□ Check»□ Cash <br />Rev 07/10/2024 <br />Payment <br />Received By <br />Contact Types <br />required <br />Email <br />^4/ 72 W <br />Email <br />_________ <br />First Name <br />________ <br />Address i ZYTuy?,,JW A'g Pr <br />Phone C // y/J Phone <br />........ <br />^'Facility Contact <br />p5\New Facility ' Existing Facility <br />eJu <br />Phone ,. Phone 7 <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 />^Application for <br />Operating Permit <br />State . <br />Application Form <br />Facility Name , t , Z1 / <br />APN <br />City <br />Last name <br />____________ <br />State i <br />T"^3P/ <br />First Name . y <br />Vi rad <br />Address . <br />Phone . . _ Phdne <br />State <br />LT# <br />C-t H . J Phone tfP/* Email <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 work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. ZA > ><7 V— #3^ 'J C~ <br />APPLICANTS SIGNATURE:------------------DATE: ----------------------— • ----------—-------- <br />^pPERATOR / MANAGER <br />50 V# <br />Type of Service <br />Requested <br />If mobile food truck or - - Uc«uA mi/e WBuiUST^ l j 'i V1N h < ! ~ i ! i / . J X <br />pumper truck ____________________/Z/5 & C-1& Y/} dl 5 /// PPH H / Y <br />□ Contractor