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San Joaquin County Environmental Health Department RACMEIVT <br /> EIVFp <br /> Application Form MAY 10 <br /> �( Facilit2024 <br /> y Name $qN� <br /> a C+!a rlwy <br /> AQUlfy cou <br /> X Site Add ss, City Stat <br /> MEN <br /> APN Supervisor Istria <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> Cansu��c��ion <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact"Fjrpes ❑Elli ing'Party O.Facility Own& ❑Facility Contact ❑Property.Owner ❑Contractor D Architect <br /> required <br /> Billing Party Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> Fir Name Last tW If contractor,indicate type and license number <br /> G ! t] 1 <br /> K Address rpCoCah n Cit , � State ZIP <br /> X Ph n O� Phone Email <br /> ��<3 - kr7Gv 7 e?el:C' <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: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 wor to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. Z q <br /> APPLICANT'S SIGNATURE: / DATE: ��i5 <br /> �I PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <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,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 /> Accepted By Assigned To Linked FA ID <br /> 17dteID5` 1�� PE 1VJ� Feg i�� 00 / RecorS912AW115t0 <br />