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□ Existing Facility <br />San Joaquin County Environmental Health Department <br />Site Addi <br />□ Change of Owner □ Repairs or Remodel □ Other <br />□ Facility Contact□ Billing Party □ Facility Owner □ Property Owner □ Contractor □ Architect <br />□ Billing Party □ Facility Owner □ Property Owner □ Contractor□ Facility Contact □ Architect <br />If contractor, indicate type and license numberime■llq <br />Ai <br />□ Contractor □ Architect□ Billing Party □ Facility Owner □ Facility Contact <br />If contractor, indicate type and license numberLast nameFirst Name <br />City State ZIPAddress <br />EmailPhonePhone <br />□ Contractor □ Architect□ Facility Contact □ Property Owner□ Billing Party □ Facility Owner <br />First Name Last name <br />City StateAddress <br />Phone EmailPhone 2026 <br /> DATE: <br />□ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGER□ PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAssigned ToAccepted By f- <br />FeePE <br />□ Confirmation #□ Check #Gi <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 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 />/ PE <br />State <br />Phone <br />///b Wlb <br />Date <br />Type of Service <br />Requested <br />Comments <br />gio G.kJ-04 <br />□ Application for <br />Operating Permit <br />If mobile food truck or License Plate Num&er VIN <br />pumper truck <br />Facility Narj^X <br />l.e Address. , . <br />APN <br />Q New Facility <br />If contractor, indicate <br />Email <br />11 n & <br />K $ JLG H • <br />& <br />^NT <br />FirsjfJiLai <br />.dcfress f <br />| U./| /\ IT-tube <br />Application Form <br />- tkroS ■___________ <br />S MfU>rt>K-F IjJrtU r"‘ <br />Supervisor District <br />[^Consultation <br />Record Number <br />Payment <br />Received By <br />Lastpyne . <br />r tn <br />Ja Drol (A a,a 1 ■CGH'A; <br />□ Property Owner <br />Sa-N JOao <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowl <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or fl <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,