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Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />State <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br /> Property Owner Contractor Architect Billing Party Facility Owner Facility Contact <br />If contractor, indicate type and license numberFirst Nam<Last name <br /> Contractor Architect Property Owner Billing Party Facility Owner <br />If contractor, indicate type and license number <br />Phone <br /> Property Owner Facility Owner Billing Party <br />Last nameFirst Name <br />DEC 16 T025StateCityAddress <br />EmailPhonePhone COUNTY <br /> OTHER AUTHORIZED AGENT OPERATOR / MANAGER <br />Title <br />Assigned ToAccepted By <br />Fee <br /> Confirmation it Check tl <br />dip ODCxXpRev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br /> Application for <br />Operating Permit <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 />Site Address <br />Supervisor District <br />PE <br />Type of Service <br />Requested <br />Comments <br />f roduce <br />Phone <br />New Facility <br />Last name (■ <br />7-c/~ <br />sta,M <br />P>cL_____ <br />Email <br /> Facility Contact <br />SAN JOAQUIN <br />_________ ENVIRONMENTAL _ —--------- <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, MfeAUWgPf^/y^liW&MJor 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 />Standards, STATE and FEDERAL law/' / I / ~ <br />APPLICANT'S SIGNATURE: DATE: I - <br /> PROPERTY / BUSINESS OWNER <br />City (ZIP^ <br />Facility Name <br />City . , <br /> Facility Contact <br />First Name. <br /> Contractor I Architect <br />PAYMENT <br />If contractor,^gi^tp><|^yykyye number <br />"Wayzit? <br />Payment <br />Received By <br />First Name . valets <br />Address <br />Phone