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□ New Facility □ Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address, <br />APN <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />Cr <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />Last name <br />□ Billing Party □ Facility Owner □ Facility Contact □ Contractor□ Property Owner □ Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address City State ZIP <br />Phone Phone Email <br />□ Billing Party □ Contractor □ Architect□ Facility Owner □ Facility Contact □ Property Owner <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br />DATE: V. <br />□ OPERATOR/MANAGER □ OTHER AUTHORIZED AGENT □ PROPERTY / BUSINESS OWNER <br />Title 5 <br />Linked FA ID <br />FeeDateLM1 <br />Rev 06/12/2024 <br />Contact Types <br />required <br />ZIP <br />^523] <br />State <br />Type of Service <br />Requested <br />Comments <br />If c^r^o^indicate type and license number <br />^5333- <br />Application Form <br />si <br />hvUD <br />Supervisor District <br />'Jfl Application for <br />Operating Permit <br />License Plate Number <br />Assigned To / x fi <br />T~° v< <br />g i(p I <br />aty <br />it •c<Drr> <br />If c^ra^o^nd^ate typ <br />State <br />If mobile food truck or <br />pumper truck <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 laws. a vAPPLICANT'S SIGNATURJB^^ Tj W S / fV <br />AcceptedByy^^ <br />’ Tpe" <br />VIN^ 9lft2 3 31AJ^2 ^oo3 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required /k-. <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby /uthori^e the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRQglJ^NTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />f~1?PLW^£ g <br />fldd7W <br />PhoneI Phone