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4 <br /> ❑ New Facility IV Fxisting Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form �� ZsC)c> <br /> �Y-Kcl� Facility Name �q <br /> l J 1 <br /> Site Address City State ZIP <br /> ('ornm• 141q .4L n ' 6-f �aTac-h�,,n C GIS i <br /> APN Supervisor District <br /> Type of Service B Application for ❑Consultation VChange of Owner ❑Repairs or Remode} ❑Other <br /> Requested Operating Permit <br /> Comments Lf <br /> V E Fes' - w o n \j')\-"e e.l 9 <br /> If mobile food truck or License Plate Number IN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ll Facility Contact Q Property Owner ❑Contractor ❑Architect <br /> required <br /> ff-Billing Party StFacilityOwner Facility Contact TO <br /> Property Owner ❑Contractor ❑Architect <br /> First nyl <br /> Last na e i} <br /> Address 1 City State ZIP <br /> 72:"--1c G a. & �-- <br /> Phone PhoneEmail <br /> ;� son wl�ee <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor 1_`1_ <br /> 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 ❑Contractilp #%tect <br /> First Name Last name If contra cto%um mpie and license number <br /> Address City State c^ ZI <br /> poyN <br /> Picone Phone EmailSAN,!p`Afko M �N� <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,ack ge that all site and/or project <br /> specific ENVIRONMENTAL HEALTH DEPARTME T hourly charges associated with this project or activity wilk be billed to me or my business as identified on this <br /> form. <br /> I also certify that I have prepared t ws applic on an that the work to be performed will be done In accordance with a SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL la <br /> APPLICANT'55IGNATURE: DATE: t7 <br /> ❑PROPERTY/BUSINESS OWNER ©OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <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 /> Accepted By � ra Z Assigned To RdlTBD <br /> LV FA IDVict1. <br /> Date PE Fee f Ror Nz ber [i <br /> a- (- (P O a f 7 e[ '[i1 0 <br /> Cl Cash Q Check R Payment <br /> Confirmation p 1 3/� <br /> Received By <br /> Rev 07/10/2024 9-1 T (/f�) <br /> �j <br /> / <br />