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□ New Facility □ Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />State (J\ <br />Supervisor District <br />Exchange of Owner□ Consultation □ Repairs or Remodel □ Other <br />License Plate Number <br />□ ■Billing Party <br />□ Billing Party □ Facility Contact □ Property Owner □ Contractor □ Architect <br />1^.Last name If contractor, indicate type and license number <br />State L| <br />■ <br />□ Billing Party □ Facility Owner □ Facility Contact □ 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 Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />CityAddress State ZIP <br />EmailPhonePhone <br />DATE: <br />□ PROPERTY/BUSINESS OWNEI □ OPERATOR / MANAGER □ OTHER AUTHORIZED AGENT <br />Title <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />□ Application for <br />Operating Permit <br />□ Property Owner <br />Application Form <br />Vw <br />U Facility Contact <br />Type of Service <br />Requested <br />Comments <br />Address <br />Phone <br />City <br />_______________ <br />□ Property Owner <br />□ Facility Owner < / <br />■ ' 7? <br />l/pNjacility Owner <br />First Namep£ <br />Phone <br />Contact Types <br />required <br />AssigriedTo <br />Site Address <br />12-3* -v- <br />APN <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site aad/or project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as ide^ljQ: <br />form. 4/L <br />I also certify that I have prepared this applicationpad-that the work to be performed will be done in accordance with all SAN JOAQUIN C0UNlYw5@^&MJeC" r <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: Z'^' —------- ----------------------------------------------- DATE: D/^3 / ,Y£7) p ***' <br /> 2025 <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, <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL IIE7Fl^Vt I <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />'<L E <br />inf <br />□ Contractor- Tn Architect