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Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />ZIPSite Address 95^7 <br /> Other Change of Owner Repairs or Remodel Consultation <br /> Architect Property Owner Contractor Facility Owner Facility Contact Billing Party <br />^Facility Contact Contractor Architectp^acility Owner Property Owner <br />If contractor, indicate type and license number <br />^530^Ci <br /> Architect Property Owner Contractor Facility Owner <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPCityStateAddress <br />EmailPhonePhone <br /> Property Owner Facility Contact Facility Owner Billing Party <br />Last nameFirst Name <br />StateCityAddress <br />EmailPhone <br />DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY/BUSINESS O' <br />Title <br />Accepted B’ <br />PE ICdO2^ <br /> Check tt Cash <br />Rev 07/10/2024 <br />OLfHi-LLJi <br />Contact Types <br />required <br />r <br />0 Billing Party <br />Payment <br />Received By <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 />Type of Service <br />Requested <br />Comments <br />and/or project <br />Hied on this <br />Application Form <br /> Application for <br />Operating Permit <br />I/^kaQ^ 4 <br />If mobile food truck or License Plate Number <br />pumper truck <br />Date <br />First Name . ) <br />Phone /% <7^ Phone <br />City State . <br />PhonejX^A?)^ <br /> Billing Party <br />Assigned Tq , ' L ■ <br />17 f ' <br /> Contractor O » 1 Architect <br />If contractor. liceffs/number <br />ZIP U <br />20^------- <br />I Phone nS^oi^oL.U <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowleag^vt/^^j^^^nc <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business aSWwIil <br />form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. OO <br />APPLICANT'S SIGNATURE: ------------------------------- DATE: G (J ------------------ <br />APN Supervisor district <br />h? 9^7/ <br /> Facility Contact <br />Linked FA ID _________________________-r <br />Record Number _SR350I419 <br />Confirmation #joWW