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Sfte Address Sv <br />APN <br />H Consultation &Changf of Owner O Repairs or Remodel □ Other <br />license Plate Number VIN <br />Q Billing Party □ ArchitectH Facility Owner □ Facility Contact □ Contractor□ Property Owner <br />□ Facility Owner O Architect□ Billing Party □ Facility Contact □ Contractor□ Property Owner <br />If contractor, indicate type and license numberFirst Name last name <br />Address s f- <br />Phone <br />□ Architect□ Contractor□ Facility Contact□ Billing Party □ Facility Owner □ Property Owner <br />If contractor. Indicate type and license numberlast nameFirst Name <br />ZIPStateCityAddress <br />Phone Phone Email <br />O Architect□ Contractor□ Property Owner□ Billing Party O Facility Owner □ Facility Conuct <br />If contractor. Indicate type and license numberlast nameFirst Name <br />State ZIPCityAddress <br />EmailPhonePhone <br />DATE: <br />□ OTHER AUTHORIZED AGE NT 8 OPERATOR/MANAGER(2 PROPERTY / BUSINESS OWNER <br />linked FA IDAssigned ToAccepted By <br />Date fee <br />tor/* 513231312. <br />DEC 2 3 2025 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />(^Application for <br />Operating Permit <br />SAN JOAQUIN COUNTY <br />environmental <br />HEALTH DEPARTMENT <br />PAYMENT <br />RECEIVED <br />tf 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 ume time II Is provided to me or my representative.______ <br />San Joaquin County Environmental Health Department <br />Application Form <br />Type of Service <br />Requested <br />Comments <br />' BILUNG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that aU 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. ~ 7 7 - 7 C <br />APPUCANTS SIGNATURE: °*T£: -Lt----------------------------------------------- <br />______ <br />Title <br />771 \ <br />Phone o I <br />All <br />ia"CA <br />State ,c./ <br />Facility Name__ <br />/ - tlgK/c’rX <br />Supervisor District <br />(^9 ooo^^ oo <br />Reco,dNun.beS[^26Sn^2 <br />(