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E Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name Tillies <br />City State ZIP 7^-2^) <br />APN <br /> Consultation Repairs or Remodel,£1 Change of Owner Other <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />$ Billing Party Facility Owner Contractor Architect Facility Contact Property Owner <br />If contractor, indicate type and license number <br />Address State <br />Phone <br /> Property Owner Contractor Architect Billing Party Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />State ZIPAddressCity <br />Phone EmailPhone <br /> Architect Property Owner Contractor Billing Party Facility Owner Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />City State ZIPAddress <br />Phone EmailPhone <br />DATE: <br /> OTHER AUTHORIZED AGENT <br />Title <br /> Cash Check # <br />Rev 07/10/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <br />Email <br />Date <br />5 \ 5 1 2-5 <br />Type of Service <br />Requested <br />Comments <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 aojiycation and thxfthe work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws/y/ / <br />APPLICANT'S SIGNATURE: / DATE: ‘ <br /> PROPERTY / BUSINESS OWNER OPERATOR / MANAGER <br />Site Address <br />______- T/ <br />Supervisor District <br />ZIP <br />Accepted By p.__________ <br />Sfconfirmation # <br />Last name x— <br />City <br />Assigned To <br />y van cisco <br />Fee . <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required 7* <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby a&thoqzfi^tfhg,' ' <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH* MP <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. ■ '■ <br />Linked FA ID £■*„ <br />Record Number <br />SR25 ______^Nr z <br />Received By <br />First Name <br />-vr <br />Phone <br /> Facility Owner <br />PE