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jXl New Facility □ Existing Facility <br />Application Form <br />5 ( <br />cr\ <br />Supervisor District <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />Billing Party ^Facility ContactFacility Owner □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license number <br />IA-C- <br />'hone <br />□ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect□ Billing Party <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />EmailPhonePhone <br />□ Property Owner □ Contractor □ Architect□ Billing Party □ Facility Owner □ Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />State ZIPCityAddress <br />EmailPhonePhone <br />□ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGER□ PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA ID <br />Rev 06/12/2024 <br />377 <br />City <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />Phone <br />San Joaquin County Environmental Health Department <br />WsOTO\ <br />Type of Service <br />Requested <br />Comments <br />"7.30 S, <br />APN <br />^Application for <br />Operating Permit <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 />SAN JOAQUIN COU 'JTY <br />-----ENVIRONMENTA <br />health departmentDate, .lOKDSl'Zd^l <br />Record Number , <br />AccepledBYJeFp C. <br />PE <br />PAYmEN tIf 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, herey^^^gJl^gQ <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.__________________________________OCT Q 3 2024 <br />Assigned To <br />^2 00) ,1^1^?