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$ New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br /> Application Form <br />Site Address <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br />License Plate Number VIN <br /> Architect Billing Party Facility Owner Facility Contact Property Owner Contractor <br />Sj, Billing Party CS. Facility Owner .0. Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number12' <br />ca <br />Phone <br />o <br /> Property Owner Contractor Architect Facility Owner <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPCityStateAddress <br />Phone EmailPhone <br /> Contractor Architect Facility Contact Property Owner Facility Owner Billing Party <br />NTIf contractor, indicate type IILast nameFirst Name <br />StateCityAddress <br />Sj <br />EmailPhonePhone <br />id th; <br />2 DATE:- <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA ID <br />2-0^Confirmation It Check tl Cash <br />Rev 07/10/2024 <br />P& 250DW^ <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />If APPLICANT is not the BILLING PAR TY, 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 />S Application for <br />Operating Permit <br />Type of Service <br />Requested <br />Comments <br /> Facility Contact <br />Supervisor District <br />PE <br />3 q Z t-/ J- j ag <br /> Billing Party <br />Assigned To <br />Fee <br />Last name <br />G G'/VZ-'V ~2- <br />l» <br />zip <br />____________ c <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, ackno\il^^t^tWfflMfi^^^)^et <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my busin”s/«ftX^f^Qh this <br />form. // <br />I also certify that I have prepared this application and tha<1he work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws, y / / / [ ------------------ - O S' <br />Atcep-3e^ C. <br />3130^5 <br />?S^I2L <br />^>350^703 <br />Payment * <br />Received By