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❑ New Facility E] Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form _ <br /> Facility Name <br /> d l <br /> Site Address � City State t� ZIP <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 Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <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 ;200? /11 0 ' -s City state � ZIP <br /> Phone Phone ! [r (� Qail �t�T��� �S <br /> ❑Billing Party 7tility 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 Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type an I T <br /> R 1 <br /> Address City State ZIP LJ <br /> ryJ <br /> A PP <br /> Phone Phone Email LVL� <br /> S d0A <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator aT authorized agent of same,acknowledge t t <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be hilted to me or my business as identified o T <br /> form. <br /> I also cert4y 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. f <br /> APPLICANT'S SIGNATURE: Y C-�2 DATE: 1,23 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT <br /> Title <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 /> C . Ceti I 'F. <br /> Date PE Fee Re ord Number <br /> @4 00 ill <br /> �53 Payment <br /> ❑❑Cash Check to Confirmation p Received B <br /> Rev 07/10/2024 <br /> ��2 <br />