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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br /> Consultation Change of Owner Repairs or Remodel Other <br /> Contractor Architect Billing Party Facility Owner Property Owner <br />IS Facility Owner Property Owner ContractorB Billing Party W Facility Contact Architect <br />If contractor, indicate type and license number <br />StateCfr <br />1 .Email <br /> Property Owner Contractor Architect Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />StateCity ZIPAddress <br />EmailPhonePhone <br /> Property Owner Facility Owner Facility Contact Billing Party <br />Last nameFirst Name <br />CityAddress <br />EmailPhone <br />DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER <br />Title <br />Assigned ToAccepted By< <br />FeePEI G 0 114 <br /> Check It <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <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 ENVIRONMEN LAI 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 />ZIP <br />^Confirmation It <br /> <br />Phonei__ <br />Type of Service <br />Requested <br />Comments <br />Supervisor District <br />I VIN <br /> Facility Contact <br />Record Number <br />" Payment <br />Received By <br />_______tall <br />l-Emai1 <br /> Facility Contact <br />Site Address . , <br />25^ ■ <br />APN <br />s,aU Z'FL <br />Lastname.first Name <br />______ <br />Address <br />'k'n F Ellrtdd- <br />Phone_ I Phone <br />ioq-&57o-q8$ <br /> Facility Owner <br />Date I | <br /> Cash <br />License Plate Number <br />cu <br /> Contractor <br />If contractor, Jjidicate type^lfifef)^’ number <br />— <br />___________________ ______________________________________ _____ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all s’tVand/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*— . z~ <br />APPLICANT’S SIGNATURE:^ b O ‘ <br /> PROPERTY / BUSINESS OWNER