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New Facility ET Existing Facility <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />H'Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />City <br />Phone <br />BfFacility Owner ArchitectBilling Party Contractor <br />If contractor, indicate type and license number <br />City <br />Lock <br />Phone <br /> Billing Party Facility Owner Facility Contact Contractor Architect <br />First Name Last name <br />Address City State <br />EmailPhonePhone <br />_DATE:_ <br /> OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br />Title <br />Assigned ToAccepted By <br />Feei(p0a <br /> Check ti <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <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 /> Application for <br />Operating Permit <br />San Joaquin County Environmental Health Department <br />ZIP <br />4S7-L,-? <br />Last name <br />Facility Name <br />Type of Service <br />Requested <br />Comments <br />ZIP <br />O|S2.L,~^ <br />TeCC C. <br />PE <br />T-'ra.nCiSCO R- <br />tty B <br /> Confirmation fl <br />9T £ <br />Email <br />Contact Types <br />required <br />f Billing Party <br />Lod?_____ <br /> Facility Contact I Property Owner <br />°aleq-30-35 <br />‘N^ash <br />Last name <br />oo Loo <br />Email <br />First Name <br />Address ' <br />rbok <br />Phone <br />State c A <br />First Name <br />Address <br />VbcA kxJ <br />Phone <br />State <br />CA <br />I Property Owner <br />If contractor, indicate ty^^ ^|y^^i^niber <br />______________________________________________________________________SA^ JOAQUi^ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowlcftftyf^^ JrfCTal <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me oHEAfTP) <br />form. <br />I also certify that I have prepared this application and tha4 the worktobe performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards. STATE and F^Q^RAL laws. z <br />APPLICANT'S SIGNATURE: ______________ ________________________MH 1 <br /> PROPERTY / BUSINESS OWNER <br />Application Form <br />v>J loc\A<o ft ZoG <br />Supervisor District <br />Linked FA ID <br />_FA 0000330 <br />Record Number <br />Payment <br /> Received By