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San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />License Plate Number <br />1 I g?-zW066188? <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />Ef Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license numberLast name <br />State <br />□ Billing Party □ Facility Owner □ Property Owner □ Contractor □ Architect <br />First Name Last name <br />Address City State <br />Phone EmailPhone <br />□ Facility Contact □ Property Owner □ Contractor□ Billing Party □ Facility Owner <br />Last nameFirst Name <br />Address City State ZIP <br />EmailPhonePhone <br />□ OTHER AUTHORIZED AGENT □ OPERATOR / MANAGER□ PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAccepted By <br />PE \Mb\ <br />fJL ft Wk.DO <br />Site Addresss. <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 />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 apoftiZation and that the <br />Standards, STATE and FEDERAL law»C7 // <br />APPLICANT'S SIGNATURE: ' <br />Date ’ <br />Qfo|<B|2.A <br />/\Je-vacla <br />Supervisor District <br />City <br />ZIP <br />95,205 <br />Type of Service <br />Requested <br />Comments <br />L___ ___ <br />Phone <br />25 <br />APN <br />Contact Types <br />required <br />^/Billing Party <br />:o be performed will be done in accordance w th all SAN JOAQUIN COUNTY Ordinance Codes, <br />FW I - <br />First Name i <br />Address <br />t5 S/g/v. ■- <br />Email <br />□ Facility Contact <br />State <br />^Application for <br />Operating Permit <br />If mobile food truck or <br />pumper truck <br />7^05- <br />If contractor, indicate type and li&FS.e number <br />It, <br />If contractor, indicate type and license4ftr^er