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Existing Facility□ New Facility <br />Facility Name <br />"PZ* C-O <br />□ Consultation □ Repairs or Remodel Another <br />VIN <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner <br />S' Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor <br />Phone <br />Grilling Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license number <br />ZIP <br />Shilling Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor. Indicate type and license number <br />ZIP <br />Phone <br />DATE: <br />PROPERTY / BUSINESS OWNER □ OPERATOR / MANAGER □ OTHER AUTHORIZED AGENT <br />Title <br />Assigned To <br />Date 11/02- <br />□ Cash □ Check# <br />Rev 07/10/2024 <br />Contact Types <br />required <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign Is required <br />AUTHORIZATION TO RELfASE 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 />Email <br />San Joaquin County Environmental Health Department <br /> Application Form <br />Email <br />Email <br />Last name <br />Statec/4 <br />State <br />C-A <br />Last name <br />City <br />State <br />—C/I- <br />ZIP <br />City <br />Last name <br />ISxhange of OwnerType of Service <br />Requested <br />Comments <br />First Name <br />__ ________________________ <br />Address <br />^4^3 Mitffa'ffirvi DY' <br />Phone <br />First Name <br />------- _______________________ <br />Address <br />Phone’ Phone <br />Site Address <br />/*? IaI_L.yi <br />APN Supervisor District <br />ZIPState <br />IxpliA/ <br />Feeaw <br />City <br />First Name <br />Address <br />5 ^^3 py <br />Phone <br />City <br />AcKp,edBy-nH^vMzHI'zi/ r <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 al! SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. /^) h / <br />APPLICANT'S SIGNATURE: (Y f—~—J DATE: <br />Payment f\ / <br />Received Byf A <br />□ Application for <br />Operating Permit <br />(JUMC 0^ 0WWZ.K <br />If mobile food truck or Ucense Plate Number <br />pumper truck <br />-----------/ A <br />□ Contractor <br />------------------ <br />tf contractor, Indicate type and llcd!& number <br />feconfihnation# L^i '