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idNew Facility 0 Existing Facility <br /> San Joaquin County Environmental Health Department R IF <br /> Application Form <br /> Facility Name [1�f� <br /> c c r �1cIu5 <br /> Site Address City State ZIP <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ©Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck '-, FT I\-ec—Z od C U 5 A <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor L]Architect <br /> required <br /> .❑'"Billing Party ❑`facility Owner ❑Facility Contact L7 Property Owner ❑Contractor C1 Architect <br /> First Name Last name if contractor,indicate type and license number <br /> Address Clty State ZIP <br /> Phone Phone Email <br /> i U-y`i�1 t f j y4zti t WJ ro 1� � Cam- <br /> ❑Billing Party ❑Facility Owner ©Facility Contact ❑Property Owner 0 Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Emall <br /> ❑Billing Party ❑Facility Owner ❑Faculty Contact ❑Property Owner E Contracto > h�tect 7- c�VED <br /> First Name Last name If contractor Pitrtre n license number <br /> Address City State EN10�p Ulj4 ZIP <br /> Phone Phone Email D <br /> �PaR MEFNr <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 ork to be performed will be done in accordance with all 5AN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDER s. 1 / �] <br /> APPLICANT'S SIGNATURE: � -- DATE: t`f 16 — G <br /> 1XPROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER 0 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 ail 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 Lime it is provided to me or my representative. <br /> Accepted By Assigned To Linked FA ID <br /> C. '\•G c 1 <br /> Da a PE Fee Record Nu ber <br /> - I � - � 1 (D03 �� �, <br /> ❑Cash C]Check# Confirmation# �q PReceived ayment By <br /> Rev 07/10/2024 ^(p,1`-u 9 <br />