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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address <br />APN <br /> Other Repairs or Remodel Change of Owner Consultation <br />VIN <br /> Facility Contact Facility Owner <br /> Architect Contractor Property Owner Facility Contact Facility Owner Billing Party <br />If contractor, indicate type and license number <br />EmailPhone <br /> Architect Contractor Property Owner Facility Contact Facility Owner <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPStateCityAddress <br />EmailPhonePhone <br /> Contractor Property Owner Facility Contact Facility Owner Billing Party <br />Last nameFirst Name <br />StateCityAddress <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNEJ <br />Title <br />Linked FA IDAssigned ToAccepted By <br />FeeDate <br /> Confirmation t! <br />Rev 07/10/2024 <br />PE <br />Type of Service <br />Requested <br />Comments <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br /> Application for <br />Operating Permit <br />Payment <br />Received By <br /> OPERATOR/MANAGER <br /> Check il <br />PAYMENT <br />If contractor, infii^?umber <br />irmed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> ^3-30 <br />First^^e^^ , <br />Address <br />4 <br />Last name /\ <br />, Phone <br /> Billing Party <br />Mar 3W«“2026 <br />SA^SSounty <br />health <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that aif site ai <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or r , <br />form. <br />I also certify that I have prepared this application and that the work to <br />Standards, STATE and FEDERAL <br />APPLICANT'S SIGNATURE: <br />ENVIRONMENTAL <br />my business as identified on this <br />3c 1 <br /> Property Owner Contractor Architect <br />Application Form <br />C Vrodoc-e_____ <br />7^10^ OyotAcl. OrcA-e <br />Supervisor District <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 HEALIH <br />DEPARTMENTas soon as it is available and at the same time it is provided to me or my representative. <br />3/WzX <br />License Plate Number <br /> Billing Party <br />State iCAr <br />s,aYA