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Mew Facility □ Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />£j <br />cJ <br />APN <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />■ETBilling Party Q'Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license number <br />State <br />Cx <br />Phone <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner <br />First Name Last name <br />Address City State <br />Phone Phone Email <br />DATE: <br />[ZPROPERTY / BUSINESS OWNER □ OPERATOR/MANAGER □ OTHER AUTHORIZED AGENT <br />Title <br />Accepted By Linked FA ID <br />PE Fee <br />ItoOS <br />□ Cash □ Check II <br />Rev 07/10/2024 <br />-lotAse, <br />ZIPState <br />wk to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />- M- 2$ <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 />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <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 thisi <br />Standards, STATE and FEDERAL-kr^sJAPPLICANT'S SIGNATURE: Q | <br />Email _ <br />I <br />'lumber <br />A P a (0,0 31 (p 0 <br />1 Payment / <br />I Received By <br />5 V <br />Type of Service <br />Requested <br />Comments <br />AePP C <br />Date <br />4-|(p-acr> <br />Facility Name <br />______ <br />Site Address <br />Record Number <br />_______I Apace, <br />^Confirmation <br />\ '< cx \ ______________________________________ <br />VIN <br /> 00GZ6 <br />□ Application for <br />Operating Permit <br />CL C <br />License Plate Number <br />&*asj= <br />'"’’gect <br />md license number <br />'026 <br />ZIP <br />— <br />euX'foS________ <br />City <br />--------- <br />5 Vo AaV <br />Assigned To <br />Last name <br />-'X <br />□ Contracto <br />If contractorT^T^fetatype ar. J il.. <br />n 202s <br />First Name <br />_________f ^.Ca Vx <br />Address_______________________1 1 <br />Phone <br />■5 i o <br />O M' \a » cj\ <br />oVV\\ <-*». <br />Supervisor District