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. * <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Site Address City State <br />o <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br />VIN <br /> Facility Contact Property Owner Billing Party Facility Owner Contractor Architect <br />Facility Ownerjfi^ling Party Facility Contact Property Owner Contractor <br />First Nam<Last name <br />Citv ZIP4- <br />p^l Email <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br />□ ArcPAYMENT Billing Party Facility Owner Facility Contact Property Owner Contractor <br />First Name Last name ir <br />Address City State ZIP <br />Phone Phone Email <br />DATE: <br /> OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER <br />Title <br />Assigned To Linked FA IDAccepted By <br />Date Fee <br />1 Architect <br />| ________ <br />If contractor, indicate type and license number <br />Contact Types <br />required <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 />If contractor, indicate type and license nui <br />JUN 0 3 202' <br />State <br />Record Number <br />Type of Service <br />Requested <br />Comments <br />O <br />Phone <br />7-yz.s- <br />Oc—4-1 ~L_ <br />3 yr a( <br />Supervisor District <br />&C I 615 <br /> OPERATOR / MANAGER <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 la^S; / — ■? — 7 -•> <7 <br />APPLICANT'S SIGNATURE: > DATE: C i 7 <br />Addroc'/^r <br />>ne <br />PE <br />C/Application for <br />Operating Permit <br />NZlxJ < I € 0^- <br />If mobile food truck or License Plate Number <br />pumper truck (1 <Z /vi i » 7 7 <br />JAN JOAQUiN COUNTY <br />environmental <br />health DEPARTMENT <br />ZIP