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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br /> Facility Owner Billing Party Facility Contact Property Owner Contractor Architect <br />^Aacility Owner Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />State <br /> Property Owner Contractor Architect Facility Owner Facility Contact <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPCityStateAddress <br />EmailPhonePhone <br /> Architect Property Owner Contractor Facility Owner Facility Contact Billing Party <br />Last nameFirst Name <br />ZIPCityStateAddress <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAccepted By <br />Record NumberFeeDate, <br /> Confirmation It Cash <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />/T <br />D <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 />ZIP State <br />Type of Service <br />Requested <br />Comments <br />Last name <br />_________ <br />Email <br />4^, <br />City <br />s/pacility Contact <br />AssignedTo t <br /> Application for <br />Operating Permit <br />License PlateWumber V VIN '* <br />ierformed will be done in accordance with all SAN JOAQUIN COUNTY Ordinan^^o^^Af f <br />x ‘7/^/ <br />Contact Types <br />required <br />Billing Party <br />'^CheeKX <br />First Name <br />AdZess^*^^ . . <br />Phone . || Phone <br />■301 4SI 18^ <br /> Billing Party <br />^<2-35^1^ <br />Payment <br />Received /) <br />Application Form <br />Facility Name . <br />LlO/V Uc&oh <br />Site Address z* <br />Supervisor District <br />If contractor, indicate type and licer^S^^^^ <br />________SEP °2.2D2i <br />------------------------------------------------------------------------------ ------JOAq,BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my buHK <br />form. <br />I also certify that I have prepared this application and that the work <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: J