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Now Facility <br />Application Form <br />ZIP <br />__Laj.Ga| <br /> Other <br /> <br /> Repairs or RemodelMxhanRe of Owner Consultation <br />VINLicense Plate Number <br />J Architect Contractor Property OwnerQTacility Owner Facility Contact Billing Party <br /> Architect Contractor Property Owner Facility Contact Billing Party <br />If contractor, indicate type and license number <br />First Name <br />Address <br />Phone <br /> Architect Contractor Facility Contact Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPStateCityAddress <br />EmailPhonePhone <br /> Contractor Property Owner Facility Contact Facility Owneri Billing Party <br /> <br />If contractor, indicate t'Last name1 First Name <br />StateCity <br /> 2025-Address <br />EmailPhonePhone <br />DATE: <br />^'OPERATOR / MANAGER <br />Title <br />Linked FA IDAccepted By <br />Fee <br /> Check W Cash <br />Rev 07/10/2024 <br /> ri Hmi hii <br />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <br />Contact Types <br />required <br />San Joaquin County Environmental Health Department <br />P 1^527 <br />zip <br />9^7/ <br />City <br />.W' <br />State <br />State <br />C/-1 <br />Date <br />(o' t Vd"2^ <br />CTacility Owner <br />xisting Facility <br />Type of Service <br />Requested <br />Comments <br />PE <br /> Property Owner <br />~ 7 .1 Phone <br />form. > <br />I also certify that I have prepared this ppplication and that the <br />Standards, STATE and FEDERAL laws J <br />APPLICANTS SIGNATURE: ----------- <br />Last name t 1 r <br />T) iftPCiVftU \ <br />City <br />work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER <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 />/elease of any and all results, geotechmcal data and/or env.ronmental/s.te 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 />Assigned To <br />^onllnn.uon v <br />Site Address <br />APN <br />Facility- Name . - . - r . <br />f j f ty.u'] I, <br />Supervisor District 1 <br />_ oc \ 5 H rs <br />| Payment ~ <br />’ teivedByA