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❑ New Facility XE�xisting Facility <br /> needs SR#) <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address Ci State ZIP <br /> � r <br /> APN Supervisor District <br /> Type of Service ❑ Application for ❑Consultation ❑ Change of Owner ❑ Repairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License PlatO Number VIN <br /> pumper truck <br /> Contact Types 64l Billing Party ❑ Facility Owner IN Facility Contact ❑ Property Owner IN Contractor M Requestor <br /> required <br /> XWWFarty ❑ Facility Owner ❑ Facility Contact ❑ Property Owner Contractor ❑Architect <br /> _ <br /> First Name 01)Omfi0a <br /> Last name T� If contractor,indicate type and license number <br /> Address • of l r,n P� I � State ZIP � 1 1Z <br /> P on Phone � � V Em I 6 <br /> 213- a4jz� r' <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 bA <br /> ❑ Billing Party J ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑Contractor ❑A r <br /> Ci <br /> First Name Last name If contractor, indicate type and ligep;e num;-?0 <br /> r D <br /> Address City State <br /> 9 <br /> Phone Phone Email <br /> tH=aeoftA <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 a Iic n and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards, STATE and FEDER L laws. 12. <br /> APPLICANT'S SIGNATURE: DATE: <br /> ❑ PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT I� % a <br /> Title � � r <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 /> Accepted By Assigned To Linked FA ID <br /> �/ ML V FA000 2540 <br /> Date q�0 25- PE.017--ILO Fee ,� Record Number <br /> ❑Cash ❑Check# Confirmation# n �n� Payment <br /> oc t3 C�?� Received By <br /> Rev 07/10/2024 2 of 6 <br />