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S <br /> New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name /� I n '� f�/I c `� <br /> 1 I V VT/ I � I lJ f O R <br /> Site Address City State ZIP <br /> l6-2-'Of Ha-clan Read C)q 533a <br /> APN Supervisor District <br /> Type of ServiceApplication for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit p }� <br /> Comments ro I Gh(u C T�tt I Y C �1QcU Enct C)a-6 <br /> If mopes food truck or License PIavN.mh� 9 3� VIN 1 , G 9 6 J )g 23 F �� c 1 <br /> pumper truck Iv `-'� t r <br /> Contact Types Billing Party ,{ Facility Owner f�;Facility Contact Cl Property Owner C]Contractor ❑Architect <br /> required <br /> [)Biding Party Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name v r Last name If contractor,Indicate type and license number <br /> Address City State ZIP <br /> 1082-c Cornynodoss tore City C <br /> Phone Phone Email <br /> -Zn9-$98- 9193 ►n e I <br /> ❑Billing Party ©facility Owner ©Facility Contact ❑Property Owner ❑Contractor 1 1 Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email aft� <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contras e ' <br /> IER ,_ <br /> First Name Last name ontractor,in is a typii license number <br /> ��V1�oNr <br /> Address City Sta e l-rlS <br /> -act✓IC ' <br /> Phone Phone Email <br /> BILLING ACKNOWLEDGEMENT:1,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 th the war to,k erformed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws, / <br /> APPLICANT'S SIGNATURE: DATE: 02 ok <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER C7 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 � n I A � Assigned To Linked FA ID <br /> Date 2 Z- y`PE I ,05 <br /> O5 Fee lX"! tJ Record IMP <br /> �Jl <br /> Payment <br /> ❑Cash ❑Check# Confirmation# Received By <br /> Rev 07/10/2024 <br /> PR2�c � + <br />