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Existing Facility□ New Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address <br />APN <br />^Change of Owner□ Consultation □ Repairs or Remodel □ Other <br />License Plate Number VIN <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 />££ <br />Phone <br />□ Facility Owner □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />ZIPAddressCityState <br />Phone Phone Email <br />□ Architect□ Property Owner □ Contractor□ Billing Party □ Facility Owner □ Facility Contact <br />First Name Last name <br />ZIPCityAddress <br />Phone Phone Email ^6 <br />DATE: <br />□ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGER□ PROPERTY / BUSINESS OWNER <br />Title <br />Assigned ToAccepted By LiiiJ <br />PE Fee Jin)6i3 <br />□ Check H□ Cash <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <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 />□ Application for <br />Operating Permit <br />ZIP <br />^53? O <br />State <br />State <br />Type of Service <br />Requested <br />Comments <br />Viol'll <br />Last name . <br />_________________ <br />BILLING ACKNOWLEDGEMENT: I, 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 that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. / // , / L/ / / 7 zT <br />APPLICANT'S SIGNATURE: / __________________________ DATE: / / Z / / Z <>’ <br />4^ <br />Email <br />31 . I d f ( ' 2- | <br />□ Facility Contact <br /> Application Form <br />B\ <br />2 7/<2 a\Y f or ■)- <br />Supervisor District <br />First Name . , <br />_____n is&LC< <br />Address <br />13 l F <br />Phone <br />□ Billing Party <br />If cofi^tBcrMidicate type and license number <br />77 <br />________LinkedFA'DFfiWV?6 <br />rec°rdNumber SR 26021^ <br />^Confirmation n 2]^ T, Q 7;j By Q