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□ New Facility □ Existing Facility <br />San Joaquin County Environmental Health Department <br />/facility Name <br />CSite Address O <br />APN <br />^J^hange of Owner □ Repairs or Remodel□ Consultation □ Other <br />□ Billing Party □ Facility Contact□ Facility Owner □ Property Owner □ Contractor □ Architect <br />ya. Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, Indicate type and license number^CFirst Name ist name <br />Phone Email <br />□ Billing Party □ Facility Owner □ Facility Contact □ Contractor □ Architect□ Property Owner <br />if contractor, indicate type and license number <br />Address <br />Phone Email <br />□ Architect□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor <br />If contractor, indicate type and license numberFirst Name Last name <br />State ZIPAddressCity <br />Phone Phone Email <br />DATE: <br />□ OTHER AUTHORIZED AGENT □ PROPERTY / BUSINESS OWNER <br />Title <br />Accepted By <br />Date <br />Rev 06/12/2024 <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 alfd 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 />0^ ,_______ <br />VIN <br />City <br />and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, v- <br /><^te z°-zip <br />Type of Service <br />Requested <br />Comments <br />TV AVI S <br />415't> VqiM C*- <br />hone Phone <br />t6o~i- <br />State <br />OB <br />Wr^6f5|r4e-ver^®hyYiAfl-con <br />I I PE <br />Application Form <br />'T-ii s- gt- <br />Supervisor District <br />License Plate Number <br />Re“rd <br />ZIP _____, ,ciszcq <br />L3^onz-a les <br />clVctc^ <br />Address <br />ASS,gnedT° -Rw <br />I <br />*atecft <br />e ■ com <br />s^.IOAvu ' <br />n^T <br />F'faName^riqn <br />4170 PdCK) ?oW <br />'f si \ - .Phonel-Ob^ <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 applicaj <br />Standards, STATE and FEDERAL laws— <br />APPLICANT'S SIGNATURE: X / <br />□ OPERATOR/MANAGER