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New Facility Existing Facility <br />Supervisor District <br /> Other Repairs or Remodel Change of Owner[^Consultation <br />License Plate Number VIN <br /> Architect Contractor Property Owner0 Billing Party Facility Owner Facility Contact <br />S Billing Party Architect Facility Owner Contractor Facility Contact Property Owner <br />If contractor, indicate type and license number <br />State CA <br />Phone <br />1 Billing Party Architect Facility Owner Facility Contact Contractor Property Owner <br />First Name If contractor, indicate type and license numberLast name <br />Address ZIPCityState <br />Phone Phone Email <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor <br />First Name Last name <br />Address City State <br />EmailPhonePhone <br />DATE: <br />JOR/MANAGER <br />Assigned To Lydia BakerAccepted By Vidal Pedraza <br />1791602FeePE7/21/25Date <br />205699629 Check » Cash <br />Rev 07/10/2024 <br />Payment <br />Received By <br />Type of Service <br />Requested <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 />Contact Types <br />required <br /> OTHER AUTHORIZED AGENT <br />Title <br /> Application for <br />Operating Permit <br />If mobile food truck or <br />pumper truck <br />Linked FA ID <br />Record NumberSO. 2-5® 12. AO <br />First Name <br />KVCVAvWC__________ <br />Address <br />VO. WW5T ST <br />Phone <br />'E Confirmation w <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 thi^ application and that thtkworl <br />Standards, STATE and FEDERAL l/wsj/ I / J <br />APPLICANT'S SIGNATURE: <br />[/PROPERTY / BUSINESS OWNER □ OPERATOR / MANA <br />City . <br />ork to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes <br />San Joaquin County Environmental Health Department <br />Application Form___________ <br />m mA <br />APN <br />City <br />___________STCCyTM <br />Email <br />Last name <br />"^5 20^ <br />State CA <br /> Archite <br />_____ <br />If contractor, indicate type and license number | W <br />1