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New Facility 0. Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />0 Change of Owner Repairs or Remodel Other Consultation <br />License Plate Number VIN <br />Xfacility Owner Billing Party Facility Contact Property Owner Contractor Architect <br />H Facility Owner Facility Contact Property Owner Contractor Architect Billing Party <br />If contractor. Indicate type and license number <br />Email <br /> Property Owner Contractor ArchitectBL Facility Owner Facility Contact Billing Party <br />if contractor, Indicate type and license number <br />City <br />Email <br /> Property Owner Contractor Facility Contact Facility Owner Billing Party <br />If contractor, indicate typ<Last nameFirst Nam^ <br />StateCityAddress <br />EmailPhonePhone <br />NT <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGERIS PROPERTY / BUSINESS OWNER <br />Title <br />AssignedTo Kadeanne LinharesAccepted By Vidal Pedraza <br />FeePE1602 179 <br />Rev 06/12/2024 Payment 2201 11895 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br /> Application for <br />Operating Permit <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 />I DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.; <br />Phone <br />- 3 \-I OO S <br />Last name <br />ZIP <br />^53^- <br />City <br />ZIP <br />ZIP <br />^3 ^6 <br />State <br />CF\ <br />State <br />C K <br />State <br />Ch <br />Type of Service <br />Requested <br />Comments <br />\y\.C_____ <br />City <br />First Name <br />________ <br />Address <br />8.35^ ST <br />Phone <br />Record Numbe^^Q£| (T]Date 5/1/2026 • <br />Last natqe <br />C t <br />Facility Name o <br />______lie- y 1C S h fwx-/KCA; <br />Site Address <br />APN <br />First Name <br />/MoVyCA-YAP/^___________ <br />Address <br />Phone ' Phone <br />ST <br />Supervisor District <br /> Architect <br />■ana licensenunroer ■ <br />RECEIVED <br />ZIP <br />01 2026 <br />1111 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowled^HffiAfeTHUE^''"™0*" <br />Specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identifie, <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^--* I r r' <br />APPLICANT’S SIGNATURE: DATE: \ ----------------