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<br /> New Facility <br />Facility Name <br />Site Addre: <br />tAPN <br /> Consultation Change of Owner Repairs or Remodel Other <br />| License Plate Numberor VIN <br />Party Facility Contact El Property Owner Contractor Architect <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />Last If contractor, indicate type and license number <br />ZIPD\c <br /> Billing Party Facility Owner Contractor Architect <br />Last name If contractor, indicate type and license number <br />City State ZIP <br />Phone Email <br /> Property Owner Facility Contact Contractor Facility Owner <br />First Name Last name <br />City State <br />Phone Email <br />DATE: <br /> 0 OTHER AUTHORIZED AGENT JOR/MANAGERPROPERTY / BUSINESS OWNER <br />Title <br />Fee <br /> Billing Party <br />First Name <br />________ <br />Address <br />________ <br />Phone <br />i If mobile food truck <br />I pumper truck <br />I Contact Types <br />required <br />APPLICANT is not the BILLING PARTY; proof of authorization to sign is required <br />UTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby autlv i? • <br />lease of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY (NVIRONMENTAL HL Al Hl <br />EPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />'"'G Application for <br />Operating Permit <br />City <br />Address <br />Phone <br />I Type of Service <br />I Requested <br />I Comments <br />Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />/MzWjPv/_______ _ <br />Xk; I'U <br />f I Supervisor District <br />stateCK C1S3 3 (p <br />I Facility Owner <br />-—__________ <br />M-SD-ZIo PE\\qO2- <br />U Facility Contact <br />— <br />Tirst Name , 1 <br />Address S . <br />Mo CondleioqU <br />' Phone . T Phone <br /> Property Owner <br />ZIP TOM <br />tltflt the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Linked FA ID <br />Record ^mb^^faOlOqfr <br />| Payment <br />Assigned To <br />i-mMi-gS <br />hitect <br />If contractor, indicate tvp-./^£T/?*'^i.|'iinroWt/ <br />.—.... r <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/oF^Vjfct <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 />•orm. <br />also certify that I have prepared this appjjj <br />itandards, STATE and FEDERAL laws, f <br />tPPLICANT'S SIGNATURE: ( <br />ie <br />So <■(' <br />State