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F1 New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name _, - - <br /> a cc w ( r <br /> Site Address ' <br /> 19 State ZIP <br /> APN Supervisor District 1 i <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments � }e- Perini ttek <br /> YN !'LQ <br /> f mobile food truck or license Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party CTFactlity Owner Yi Contact 7 <br /> Property Owner ❑Contractor 11 Architect <br /> First Name Last ns', <br /> e If contractor,indicate type and license number <br /> AddressJ I � t A v City State ZIP <br /> L1L e rn�rC A q4532 <br /> one Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name Itcontractor,indicate type and license number <br /> AddressState ZIP <br /> it-rct"l rApt. <br /> Cit u r i a n a 4 <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contract ,i t ar em number <br /> - u <br /> Address City State "IF <br /> Phone Phone Email <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same, I and/or project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be bilge lthJ0ffi'f"TVfiM1Tied on this <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,aws. �� � DATE' +� _0, <br /> APPLICANT'S SIGNATURE:_)M — -* <br /> C3 PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER O 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 JflAQUIN 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. Assigned To Linked FA ID <br /> c' C' <br /> . 3 etc 1003 Record Number <br /> Date -7q <br /> 3 <br /> 2 payment <br /> ❑Cash ❑Check q ❑Confirmation# 6 '�b 222 Received By aill <br /> Rev 07/10/2024 {�� <br /> 2V 2- <br />