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K^New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br /> Change of Owner Repairs or Remodel Other Consultation <br />License Plate Number VIN <br /> Contractor Architect Billing Party Facility Owner Facility Contact Property Owner <br /> Property Owner Contractor Architect Facility Contact Billing Party Facility Owner <br />If contractor, indicate type and license number <br /> Property Owner Contractor Architect Facility Contact Facility Owner <br />If contractor, indicate type and license numberFirst Name Last name <br />City State ZIPAddress <br />EmailPhonePhone <br /> Contractor Architect Facility Contact Property Owner Billing Party Facility Owner <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPCityStateAddress <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA ID <br /> Check tl Cash <br />Rev 07/10/2024 <br />I <br />Contact Types <br />required <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 apjjlu <br />Standards, STATE and FEDERAL laws* <br />APPLICANT'S SIGNATURE: <br />Payment <br />Received By <br />State <br />6^ <br />State ZIP <br />^Confirmation it <br />Type of Service <br />Requested <br />Comments <br />Record Number <br />^Application for <br />Operating Permit <br />If mobile food truck or <br />pumper truck <br />Hcai a <br />Supervisor District <br />W__ <br />Phone <br />PE <br />Application Form <br />oc/. <br />Z!P <br />First Name <br />C} Io <br />Phone <br /> Billing Party <br />Accepted By <br />C- <br />Date <br />|(2>U<2)(2.S <br />Last name <br />____________<0 _______________ <br />frcwofi'l’ <br />Email 9 M <br />thatjhe work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required OPT 1 <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, herroy at/liyi <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY EN^lj^lMENTAL HEALTFr <br />DEPARTMENT as soon as it is available and at the same time It is provided to me or my representative.________ eL^Qt/^co/71, * <br />Assigned To „ <br />LycliCX. o. <br />Fee