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I <br /> ❑ New Facility Existing Facility <br /> tR (needs SR#) <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name �"� .-----, <br /> Site Address i City State ZIP <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation ❑ Change of Owner epairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types fig Billing Party ❑ Facility Owner ®Facility Contact ❑ Property Owner IN Contractor ® Requestor <br /> required <br /> Billing Parry ❑Facility Owner ❑Facility Contact ❑ Property Owner ontractor ❑Architect <br /> t� Last name If contractor, indicate type and license number <br /> r r a arte, t <br /> Address City _ State ZIP ' <br /> 0 1k2- <br /> Phone Phone Email <br /> ❑ Billing Party ❑ Facility Owner ❑Facility Contact ❑ Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> BILLING ACKNOWLEDGEMENT:1,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 a plic tion and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL ws. <br /> APPLICANT'S SIGNATURE: i 5 DATE: <br /> ❑ PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT�i 1 ril ��rvct 1 <br /> Title <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,geotechnicai 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 /> Accepted By `�-r v � Assigned To Linked FA ID <br /> `J ,�F �9/7 FAmOmmG-40 <br /> Date 13 2� PE try ® i F / Record Number <br /> ❑ Gash ❑ Check# I ❑ Confirmation# "Received <br /> nt <br /> By <br /> Rev 07/10/2024 2 of 6 <br />