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New Facility <br />i; <br />San Joaquin County Environmental Health Department <br />■ ^Facility Name <br />APN <br />P^hange of Owner Consultation Repairs or Remodel Other <br />VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />"^*6illing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />First Name If contractor, indicate type and license number <br />City State <br />Email <br />'□ Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberLast name <br />State <br />Phone Email <br /> Property Owner Contractor Architect Billing Party Facility Owner Facility Contact <br />If contractor, indicate type and license numberLast nameFirst Name <br />State ZIPCityAddress <br />Phone EmailPhone <br />7 DATE: <br /> OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER <br />Title <br />PE <br /> Check H Cash <br />Rev 07/10/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <br />Payment <br />Received By <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 hbufly charges associated with this project or activity will be billed to me or my business as identified on this <br />form. V <br />I also certify that I have prepared this applicatioryai <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />ZIP <br />State <br />Type of Service <br />Requested <br />Comments <br />:hat the work to be performed will be done in accordance with ail SAN JOAQUIN COUNTY Ordinance Codes, <br />ZIP - <br />9^3 S') <br />Supervisor District <br />Assigned To <br />Feesra <br />Application Form <br />Phone <br />First Name <br />MdressJ/^ zJL <br />Phone <br />License Plate Numberg V K ^Q(e <br />Accepted By <br />C. <br />Date <br />Ol- 57-35 <br />Z'P<%W <br />^OPERATOR/MANAGER OTHER AUTHORIZED AGENT _____________ <br />[i Title <br />If APPLICANT is not the BILLING PARTY, proo^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 addres/^ks^by authorlC^jX' <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMrN^LflEALI H <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. ^02^ <br />Record Number <br />□ Confirmation It | <br />Addres7/^^ Li- | <br />Phone