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Facility Name <br />State <br /> Other Repairs or Remodel Consultation <br />License Plate Number VIN <br /> Architect Contractor Billing Party Facility Owner Facility Contact Property Owner <br />^^^illing Party Architect^S^acility Owner ^SJJacility Contact Contractor Property Owner <br />If contractor, indicate type and license numberLast n, <br />,ity State <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor <br />First Name Last name <br />Address City State <br />Phone Phone Email <br /> Billing Party Facility Owner Facility Contact Property Owner <br />First Name Last name <br />Address City State ZIP <br />Phone Phone Email <br />Ration and that th< <br />____ DATE: <br /> PROPERTY / BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br />Title <br />Assigned To <br />O Cash <br />Rev 07/10/2024 <br />Application Form <br />U <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <br />Phone <br />£1 <br />Email <br />J^Confirmation II <br />^(Change of Owner <br />Supervisor District <br />l_ \ <\ V\ <5\ ( <br />- <br />I Architect <br />If contractor, indicate tyfre^l <br />DVZZ-Z^ <br />HE, <br /> Contractor <br />Payment <br />Received By/ <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 <br />Standards, STATE and FEDERAL laws.f^ <br />APPLICANT'S SIGNATURE: <br /> Check « <br />rprlttabe performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />01 /^i <br />93-3-? p <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 <br />Site Address . . <br />Type of Service . <br />Requested I <br />Comments * <br />If contractor, indicate type and license number <br />Fi^Name x , ___________, <br />( r CrT <br />Address 0 ~ M <br />i'SCVO 5. <br />wir -