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B^Existing Facility□ New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />z,pl <br />APN Supervisor District <br />E'Change of Owner□ Consultation □ Repairs or Remodel □ Other <br />License Plate Number VIN <br />□ Billing Party □ Facility Owner □ Property Owner □ Contractor □ Architect□ Facility Contact <br />x__________ <br />STacility Owner Q'Facility ContactBilling Party □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license number <br />Address <br />Phone <br />(^7^ <br />□ Billing Party □ Facility Owner □ Property Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address City State ZIP <br />Phone Phone Email <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor <br />First Name Last name <br />Address City State <br />Phone Phone Email <br />□ PROPERTY / BUSINESS OWNER □ OTHER AUTHORIZED AGENT <br />Title <br />Linked PAIDAccepted By Assigned To <br />□ Confirmation tt□ Cash <br />Rev 07/10/2024 <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 />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />□ Application for <br />Operating Permit <br />□ OPERATOR/MANAGER <br />]Las,nameFirst Name <br />I ^Check U <br />Type of Service <br />Requested <br />Comments <br />Standards, S.T^JE and FEDERAL law: <br />APPLICANT'S SIGNATURE:^ <br />| Facility Name <br />Site Address <br />/ <br />□ Facility Contact <br />Dat^-37-<35 Rai°rdNumbe5R.7t50itag <br />Payment / 77*/^ <br />Received By^ W U <br />ie T ~ Phi <br />1K-frbi.' V <br />If contractor, indicate typi <br />------,SxWV( <br />>A^dd4icanse numbei** <br />---- <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 />llaws.,x^XZ&^--------- ------------- <br />'■ II I 7,Z <br />V i did P- <br />PE