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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address <br />APN <br /> Consultation Repairs or Remodelihange of Owner Other <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />'prilling Party Facility Owner Property Owner Contractor[Facility Contact Architect <br />First Name If contractor, indicate type and license number <br />Address <br />Phone <br /> Billing Party Contractor Architect Property Owner <br />If contractor, indicate type and license numberLast name <br />State <br /> Contractor Facility Owner <br />First Name Last name <br />City StateAddress <br />EmailPhonePhone <br />the <br />DATE: <br /> OPERATOR/MANAGER <br />Title <br />Accepted By <br />FeeDati <br /> Cash <br />Rev 07/10/2024 <br />I <br /> Property Owner <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />Payment <br />Received By <br />State <br />VIN <br />Type of Service <br />Requested <br />Comments <br />o\d <br />z'VT3z>L/ <br />Email <br /> Facility Contact <br />State <br /> Application for <br />Operating Permit <br />truck or License Ptfffe Number <br /> Billing Party <br />"--‘i X □ Check ti <br />u?_____________i <br />rnvi.v _ Phone <br />^(Facility Owner <br />Linked FA IQ. <br />FfX 002^^'4 0 <br />_________________ <br />^Confirmation# | <br />City <br />’^f^this <br />fbe perjafmed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />______ DATE: <br /> OTHER AUTHORIZED AGENT <br />If contractor, indicate typ <br />Up r,-, ____ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge th7t4^jiJS/eZi<^pr6jOcl <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly chargesj^eciated with this project or activity will be billed to me or my business as ideMHfft^this <br />form. <br />I also certify that I have prepared this applp <br />Standards, STATE and FEDERAL laws^^ <br />APPLICANT'S SIGNATURE: <br />^PROPERTY/BUSINESS OWNER ' <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 HEAL IH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative <br />Last name <br />l ________ <br />' IlT-S <br />Assigned To J / <br />Application Form <br />Supervisor District I I <br />First Name . . • <br />(k- rV] k,n <br />AddreiS VaaI^W QJ <br />_ Phone Email <br />________________ <br /> Facility Contact Architect