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New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name rt �dGq'� <br /> Site Address v% 5 City sr State ZIPG a 4 <br /> APN t Supervisor District )C I <br /> Type of Service ❑Application for LJ Consultation LJ 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 <br /> Contact Types ❑Billing Party ❑Faciiity Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> i>� ('Al GGIyGti. <br /> First N me Last name t� If contractor,indicate type and license number <br /> C./ ,C" <br /> Add ess v� City State Zip <br /> Phone Phone Email <br /> -L7 _ yzzSZq zdi"cl 35b TrrF7 <br /> C7 Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City state ZIP <br /> Phone Phone Email ! M F ENT <br /> El Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner El Contractor ect <br /> First Name Last name If contractor,N d t t e Wense number <br /> Address City State EWG-%Wul NTIf <br /> TAL <br /> Phone Phone Email <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 thi o d that the work to be performed will be done in accordance with all 5AN JOAQUiN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL la L !3. <br /> APPLICANT'S SIGNATURE: DATE: Z3 <br /> ❑PROPERTY/BUSINE55 OWNER ❑OPERATOR/MANAGER ❑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 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 /> Accepted B Assigned To Linked FA tD <br /> Date PE Fee 0 Record Number O <br /> Payment <br /> ash 1�—� ❑Check# ❑Confirmation# Received By <br /> Rev 07/10/2024 <br /> —VC <br />