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□ New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address <br />APN <br />□ Repairs or Remodel□ Change of Owner □ Other <br />License Plate Number VIN <br />□ Billing Party □ Contractor□ Facility Owner □ Facility Contact □ Property Owner □ Architect <br />0 Facility Owner □ Property Owner □ Contractor □ ArchitectBilling Party □ Facility Contact <br />If contractor, indicate type and license number <br />Phone Email <br />□ Property Owner □ Contractor □ Architect□ Facility Owner □ Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />ZIPCityStateAddress <br />EmailPhonePhone <br />□ Property Owner□ Billing Party □ Facility Owner □ Facility Contact <br />First Name Last name <br />CityAddress <br />EmailPhonePhone <br />DATE:4-X-+ <br />□ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGER□ PROPERTY / BUSINESS OWNER <br />Title <br />Linked PAIDAssigned ToAccepted By <br />Confirmation It□ Check «□ Cash <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 />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 />ZIP <br />5 2 ^2 <br />State <br />ZIP <br />Type of Service <br />Requested <br />Comments <br />[^Consultation <br />Application Form <br />JTomS Market <br />14SI H I Dorado <br />Supervisor District <br />First Name <br />Address <br />. —Phone <br />□ Billing Party <br />PAYMENT <br />□ Contract^ £ C E IIV6E>«ct <br />If contractorpr^gat^jt^e ^gEJjcense number <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 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. /i J rj r' <br />APPLICANT'S SIGNATURE: k < <' I C DATE: 12. / ' / / '2 <br />Vidol Pedraza <br />PE Kp03l <br />Lu di cl Baker <br />Fe^/7? / <br />Last name <br />City <br />Date <br />12-11-^ <br />U-L <br />Record Number _ <br />State <br />__CA <br />5 teSAN JOAQUIN ddUNTY <br />----------E N VI RO N Ml INTAL---- <br />HEALTH DEPARTMENT