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Sf^Existing Facility <br />□ New Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />ZIPWJ33StateCASite Address <br />APN <br />Change of Owner □ Repairs or Remodel □ Other□ Consultation <br />VINLicense Plate Number <br />□ Architect□ Property Owner □ Contractor□ Facility Contact□ Billing Party □ Facility Owner <br />g/Facility Owner facility Contact □ Architect□ Property Owner □ Contractor <br />If contractor, indicate type and license number <br />□ Contractor □ Architect□ Facility Owner □ Facility Contact□ Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPCityStateAddress <br />EmailPhonePhone <br />□ Contractor□ Property Owner□ Facility Contact□ Billing Party □ Facility Owner <br />Last nameFirst Name <br />StateCityAddress <br />EmailPhonePhone <br />•Z. ~ 2. 6DATE:Z- <br />□ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGER□ PROPERTY / BUSINESS OWNER <br />Title <br />Accepted By 3.0^ 'A- <br />ifroa <br />□ Confirmation «□ Check M <br />Rev 07/10/2024 <br />Application Form <br /><r i k 3^-5 I l'S <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />□ Application for <br />Operating Permit <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 />Phone -4/^3 ) <br />Date <br />51-5- Q(o <br />^^Cash <br />Type of Service <br />Requested <br />Comments <br />S4-oc^4or\ <br />First Name <br />____________ <br />Email <br />it - r <br />Vidal PeJraza <br />PE <br />tOpe-and license number5 — <br />5Kl- Premon-t St- <br />Supervisor District <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 andFEDERAL laws. /) <br />APPLICANT'S SIGNATURE: _______ <br />If contractor, i <br />____ <br />Assigned To-. | . .Clauajft Muro <br />FeeAm <br />Linked FA <br />Record Number5Ra.to01.%93 , , <br />I Payment <br />Received P <br />name | <br />State <br />& (/ (2 r C , <br />□ Property Owner