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p] New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />s,& <br />Supervisor District <br /> Change of Owner Repairs or Remodel Other Consultation <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />Billing Party S3 Facility Owner JZkFacility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />Phone <br />• CC*r*-» <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor <br />First Name Last name <br />Address City State ZIP <br />Phone Phone Email <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br />DATE: <br /> OTHER AUTHORIZED AGENT <br />Title <br />Linked FA IDAccepted By <br />IO- <br />PE <br />Rev 06/12/2024 <br />4172. DO Hl +33^ <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 />Meyj Centring per mi f <br />If mobile food truck or <br />pumper truck <br />State <br />Record Number^70^^ 3 <br />Email <br />Type of Service <br />Requested <br />Comments <br />Site Address ,. <br />APN <br /> Architect <br />if contractor, Indicate type and license <br />Application for <br />Operating Permit <br />City ZIP <br />Last name - packed___ <br />City <br />S^XAcTPyx <br />Assigned To <br />_iv i ck- <br />Fee <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 prepar^athl’s application and th<Q the work to be performed will be done In accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAblawsJ * . \ | I <br />APPLICANT'S SIGNATURE: —y <?/c/ C DATE: u i <br /> PROPERTY / BUSINESS OWNER OPERATOR / MANAGER <br />First Name