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❑ New Facility VExisting Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> �►'� �S v�i�G�o tin <br /> Site Address410 <br /> City l State ZIP <br /> rl?—oZ <br /> APN Supervisor District <br /> Type of Service p Application for ❑Consultation ange of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> if mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party LJ Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> C1 Billing Party Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address Cit State ZIP <br /> Phone k" Phone Email <br /> apt-3 Z8- I L T !� �Rva e� 1Mdbf l �Co <br /> ❑Billing Parry T❑Facility Owner ❑Facility Contact El Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner 0 Contractor � t <br /> First Name Last name If contractor,Tete type umber <br /> Address [[// TT <br /> City State a�O�QU �C <br /> Phone Phone Email 4 N, <br /> 81LLING ACKNOWLEDGEMENT:1,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site nd/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 application and that the w e will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL ws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> ROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <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 --s- �� C Assigned To C Linked FA ID <br /> e � (au iu N1. <br /> Da D PE �� Fee Record Number <br /> 9 S a5 <br /> Payment <br /> Cos ❑Chetk# Confirmation# "/J � r� <br /> "f hh ll Received By <br /> Rev 07/10/2024 V v V t <br />