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❑ New Facility Existing Facility <br /> (needs SR#) <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name r <br /> Site Add re City State ZIP <br /> Ot "IN <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑ Consultation ❑ Change of Owner ❑ Repairs or Remodel ❑ Other <br /> Requested Oppeerattiingg Permit <br /> Comments �`111i1 LA \ -ca <br /> d <br /> If mobile food trucA or J License Plate Number VIN <br /> pumpertruck <br /> Contact Types RI Billing Party 1-6��wner ® Facility Contact ❑ Property Owner ® Contractor ® Requester <br /> required <br /> Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner o ratter H ❑ Architect <br /> O J,t4 <br /> First Name ` Last naala if contractor, indicate ype and license number <br /> C ` A <br /> Address CIM State ZIP <br /> Phone Phone Email <br /> o - ,o: l/)r�� ��a •tf^ Yv -Irk' C�►'L <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ A ,itect <br /> Firsi 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 pli- tion and that the work to be performed will be done in accordance with all SAN JOA<Q'UII-N-COUNTY Ordinance Codes, <br /> Standards, STATE and FEDERAL law /� -- ��� J <br /> APPLICANT'S SIGNATURE:/ ` / DATE: A <br /> ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER OTHER AUTHORIZED AGENT C- Y-('. .(Y1tk <br /> Title ED <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 a �ri(p�e 1JtJeQ <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALhi V �u/ 2025 <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> UWTr <br /> AcceAed By I Assigned o- Linked FA ID E <br /> J e V AV L FA�m� $5 H�T1'� 1)EP ENT <br /> Date 2 PE Fee c., Number <br /> : Record R a50 1 1 0013 <br /> ❑ Cash ❑ Check# confirmation# Or 1 a 402Oq ,LIN Payment <br /> Received By <br /> Rev 07/10/2024 <br />