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4 <br />□ New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />State <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license number <br />State ZIPc^0 <br />( c' -//7 <br />□ Billing Party □ Facility Owner □ Property Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license numberLast name <br />City ,State <br />-pf yClC) <br />T Phone-' <br />□ Billing Party □ Facility Contact □ Contractor□ Facility Owner □ Property Owner □ Architect <br />First Name Last name <br />Address City State <br />wPhonePhoneEmail <br />□ PROPERTY / BUSINESS OWNER □ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGER <br />Title <br />Linked FA IDAccepted By <br />/ A? Z? <br />I 6 D 3 <br />□ Check ti .unfirmation # <br />Rev 07/10/2024 Ip <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 />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />Email <br />/fe u <br />ZIP <br />Site Address <br />APN <br />Address <br />Phone <br />Fee <br />.g I ~7 7 <br />If contractor, indicate type a <br />DATE: <br />l/Existing Facility <br />Type of Service <br />Requested <br />Comments <br />^54^ P) 'i id7 1'2*' x <br />□ Facility Contact <br />□ Application for <br />Operating Permit <br />1/C) <br />City <br />Last name <br />ic/W- <br />Phone <br />_ a/pM'ChO <br />Supervisor District <br />Record Nunbe, <br />Payment <br />Received ByUMzC- <br />Date <br />m'// <br />License Plate Number <br />First Name <br />______ <br />Address <br />Phbne <br />PE <br />Assigned To <br />ZIP *" <br />______________________________________________________ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledgiSJ^fUj^iMyMo/oWSi’x^ct <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as laemfft <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 />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: 't ■f-''fl? O