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Existing Facility <br />San Joaquin County Environmental Health Department <br />Site Address ZIP ^^33 7 <br />APN <br /> Repairs or Remodel Consultation Change of Owner Other <br />tskBilling Party Property Owner Contractor Architect Facility Owner Facility Contact <br /> Contractor ArchitectGhJilling Party Facility Contact Property Owner Facility Owner <br />If contractor, indicate type and license number <br />ZIP <br />Email <br />/X <br /> Contractor Architect Property Owner Facility Contact Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />State ZIPCityAddress <br />EmailPhonePhone <br /> Architect Contractor Property Owner Facility Contact Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPStateCityAddress <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR / MANAGER'ROPERTY / BUSINESS OWNER <br />Title <br />^TY <br />Linked FA IDAssigned To Gehane FahmyAccepted By yjjai Pedraza <br />FeePEDate 17910/13/25 1602 <br />Rev 06/12/2024 <br />Contact Types <br />required <br />^/Application for <br />Operating Permit <br />State <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required 34^ <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hegb <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIROfflt^; <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />Last name/g> <br />Type of Service <br />Requested <br />Comments pre - Idra-frori <br />VINLicense Plate NumberIf mobile food truck or <br />pumper truck <br />State <br />b/wew Facility <br />________ <br />First Name . . <br />ft [ <br />Phone. Phone <br />City <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 />I also certify that I have prepared this applieaUQn .lid tKSUhe work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordm^^WlTa . „ <br /> DATE. <br />m 3 <br />m alid tl <br />Application Form <br />//^ t,u. Alg/iiy _ <br />Supervisor District