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San Joaquin County Environmental Health Department <br />Application Form <br />Facility NameA <br />City <br />^Repairs or Remodel Change of Owner Other Consultation <br />VIN <br />^.Billing Party Property Owner Contractor Facility Owner Facility Contact <br />Facility Contact Property Owner Contractor Architect Facility Owner <br />If contractor, indicate type and license number <br /> Contractor Property Owner .Architect Facility Owner Billing Party <br />If contractor, indicate type and license numberI <br />Address <br />D <br /> Contractor Architect Facility Owner Facility Contact Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />State ZIPCityAddress <br />Phone EmailPhone <br />X DATE: <br />X PROPERTY / BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br />Title <br />Assigned To <br />FeeDate <br />4/W I h <br />Contact Types <br />required <br />ZIP <br />ZIP <br />^33 7 <br />Phone <br />City <br />^Architect <br />State <br />0^ <br />State <br />Type of Service <br />Requested <br />Comments <br />Phone <br />Site Address_J| In <br />APN <br />c,co' <br />State <br />Cctivfi la's CoJ^.______ <br />\AJ- In <br />Supervisor District <br />T-j:- <br />If mobile food truck or <br />pumper truck <br />Billing Party <br />Email <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 ad^j <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIR <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 />License Plate Number <br />Last name__/y ______ <br />City <br />________________ <br />Email ' <br />_____c______ <br /> Property Owner <br />Linked FA ID <br />Record Number <br />srzw?2-8® <br />Last nameFirst Namgjk « __nun ____ <br />Address . . <br />Phone Phone <br />Accepted Bw—s <br />PE <br />LaKv__________ <br />tEmail i 7 <br />* fob* <br /> Facility Contact <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 thsfOhe work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws(| -. r V 'OU zs <br />APPLICANT'S SIGNATURE: I A DATE: <br />.s, hereb/WhytoBtfie <br />' tfOfc^JAL HEALTH 7 <br />First Name .