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a <br /> �7q <br /> ❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form P (L 5� b 32 <br /> Facility Name <br /> Site Address City State f <br /> I <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation hange of Owner ❑Repairs or Remodel 0 Other <br /> Requested Operating Permit <br /> Comments <br /> if mobile food truck or License Plate Number VIN <br /> pumper truck 3 <br /> Contact Types 0 Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> M Billing Party glacility Owner ErFacllity Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name I last named If contractor,indicate type and license number <br /> % <br /> Address r <br /> > to L c K fotq C ft o <br /> brie Phone Errialf <br /> Q Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ll 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 ❑ContractorAr6 i�tt <br /> el <br /> First Name Last name If contractor, <br /> ••11 Iccaate type a ll a number <br /> .IN Of <br /> Address City Stat841V do., 4W6 <br /> Phone Phone Email �,Q�r � � 47-y <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that aII 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 /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: f dJt I (> <br /> ❑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,1,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 le- -C+" C Assigned To Ka � f Linked FA ID F ^ 0 O ^ I�O- <br /> Date _ /^ PE Fee ( -7 9 Record Number <br /> I li/ U ry Payment <br /> 14- <br /> Q Cash ❑Check P Confirmation q �[ — <br /> """ JJJ vvv Received By <br /> Rev 07/10/2o24 <br /> S <br />