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VrNew Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility N oe// 6 t x woe 44 <br /> Site Address 9 fe I e P r�Or Ave- <br /> City statue ZIP ��O <br /> APN Supervisoistrict l/• <br /> 212--140- 5-r D qq <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel PDther <br /> Requested Operating Permit <br /> Comme L <br /> If mobile food truck or Licen a Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party ❑Facility Owner ❑Facility Contact IKpr.perty Owner ❑Contractor ❑Architect <br /> FU;tX &.mm erCe Last name / If contractor,indicate type and license number <br /> Addres qV / 1Jor V S�r�� Q �t� /, Q State <br /> hOSg' ZS'3_SrTi 7 S �f or4-e etI vetPm .e-c)iyl <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email :P ilENT <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor <br /> First Name Last name If contractor,indlca a?Gtengtyber <br /> Address City State JOAMIJV COUNTY <br /> ENVI <br /> Phone Phone Email REALTH r1hEPARTMENT <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 thi p cation a h t the wor be pe ed wil <br /> al be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL Taws. >a r <br /> APPLICANT'S SIGNATURE: DATE: <br /> VROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <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 /> Accepted By Assigned To_.. �v Linked FA ID <br /> Date PE�p op <br /> � Fee �� Record Number I I <br /> C,1 / Payment <br /> ❑Cash ❑Check# tonfIrmation# 3fO S U - Received By <br /> Rev 07/10/2024 <br />