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□ New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name LC <br />City <br />APN <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />License Plate Number VIN <br />□ Property Owner □ Contractor □ Architect <br />□ Billing Party 3 Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />I CVS <br />Address <br />Phone,Email <br />□ Property Owner □ Contractor □ Architect□ Facility Owner □ Facility Contact <br />If contractor, indicate type and license numberLast nameFirst Name <br />Address City State ZIP <br />EmailPhonePhone <br />□ Property Owner □ Contractor□ Billing Party □ Facility Owner □ Facility Contact <br />Last nameFirst Name ier <br />City StateAddress <br />Phone EmailPhone <br />DATE: <br />□ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGER□ PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAccepted By <br />PE 1^3 <br />□ Check tt <br />Rev 07/10/2024 Rm <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />□ Application for <br />Operating Permit <br />Payment <br />Received By <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 HEALIH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />ZIP <br />^5^ MO <br />Type of Service <br />Requested <br />Comments <br />B Billing Party <br />City | . <br />_____sW.Mnr) <br />Existing Facility <br />3 Facility Contact <br />7 ?/ £ V\\jc yry dr <br />rl.-.ie,-. . Phone <br />□ Billing Party <br />Facility Owner <br />If contractor, indicate typ^aW^J^aniWbe <br />^4/^ <br />_____________________________________________ __ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all sitV^/pr project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identifred 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 COUN IY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. I I. \ \ / i ) <br />APPLICANT'S SIGNATURE: H______________________ DATE: * / / z~ __________ <br />State <br />Cfi <br />______LWiStoo <br />^Confirmation# <br />identifier <br />A5s'gnedToL^i^ <br />Site Address <br />333 l\\/p <br />Supervisor District <br />“AG- <br />□ Cash