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t S^xisting Facility□ New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Site Address State ZIP <br />.a <br />APN <br />□ Repairs or Remodel□ Consultation □ Change of Owner □ Other <br />License Plate Number VIN <br />□ Contractor □ Architect□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner <br />□ Contractor □ Architect□ Facility Contact □ Property Owner□ Billing Party □ Facility Owner <br />If contractor, indicate type and license number <br />77 <br />□ Architect□ Contractor□ Property Owner□ Billing Party □ Facility Owner <br />If contractor, indicate type and license number <br />Phone <br />□ Architect□ Property Owner □ Contractor□ Facility Owner□ Billing Party <br />Last nameFirst Name <br />City StateAddress <br />EmailPhonePhone <br />t b 31 - 7-SDATE: <br />'■d PROPERTY / BUSINESS OWNER □ OTHER AUTHORIZED AGENT □ OPERATOR / MANAGER <br />Title <br />Linked FA IDAssigned ToAccepted By <br />□ Confirmation tl□ Check tt□ Cash <br />Rev 07/10/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <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 HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />^7 /V z^7 <br />Supervisor District <br />State <br />City <br />ZIP <br />Last name <br />City <br />City <br /><r57^/^7/>7 <br />Last name <br />Date <br />10-31-35 <br />State <br />Type of Service <br />Requested <br />Comments <br />Email <br />j ^5^ iaulnKgo . <br />□ Facility Contact <br />First Name <br />KimL___________ <br />Address <br />TA?)7- S&Vfl-SWA <br />Phone <br />Email <br />□ Facility Contact <br />Record Number , <br />ZIP <br />c. <br />7^2^ <br />Q Va 8 r 3 <br />If contractor, indicate type and license number <br />Ocf 3 I 20^_____ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, aSn^^AQWIProiec 1 <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to m^piy on this <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 COUNTW^WrTance Codes, <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />First Name <br />Address <br />Phone Phone <br />707-W?________ <br />ClauJha- M- <br />Fee/ go