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New Facility □ Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />E'l b’te <br />□ Consultation □ Repairs or Remodel□ Change of Owner □ Other <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />□ Billing Party □ Facility Owner □ Property Owner □ Contractor □ Architect□ Facility Contact <br />If contractor, indicate type and license numberLast name <br />□ Billing Party □ Facility Owner □ Property Owner □ Contractor □ Architect□ Facility Contact <br />First Name Last name <br />StateAddressCity <br />EmailPhonePhone <br />□ Contractor□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner <br />First Name Last name <br />Address City State ZIP <br />Phone Phone Email <br />7/7^DATE: <br />□ OTHER AUTHORIZED AGENT □ PROPERTY / BUSINESS OWNER □ OPERATOR/MANAGER <br />Title <br />Linked FA IDAssigned To <br />Record Number <br />Rev 06/12/2024 <br />PR2scm?4 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <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 />□ Application for <br />Operating Permit <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 law; <br />APPLICANT'S SIGNATURE: _ <br />Phone jr yo <br />■ CcJ <br />City <br />ZIP <br />ZIP <br />G <br />License Plate Number <br />Site Address 1^-11- 5 <br />Type of Service <br />Requested <br />Comments <br />First Name <br />Address <br />U A < O <br />Supervisor District <br />_ite Adc <br />APN <br />^OC Al ar 7 <br />Phone <br />State c <br />City <br />Accepted By <br />-JeCC C- <br />State <br />r <br />PE <br />If contractor, indicate type and lie <br />OCT 3 1 <br />If contractor, indicate type and license number