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□ Existing Facility <br />StaJ <br />\Qd <br />iupervisor District <br />□ Other□ Repairs or Remodel□ Change of Owner□ Consultation <br />□ Contractor□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party <br />□ Architect□ Contractor□ Property Owner'BTacility ContactsB^Facility OwnerpEJ-Billing Party <br />If contractor, indicate type and license number <br />□ Architect□ Contractor□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPStateCityAddress <br />EmailPhonePhone <br />□ Contractor □ Architect□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party <br />Last nameFirst Name <br />StateCityAddress <br />EmailPhonePhone <br /> DATE: <br />□ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGER□ PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA ID <br />T-so-'Z-V, <br />CT□ Check ff□ Cash <br />Rev 07/10/2024 <br />Contact Types <br />required <br />San Joaquin County Environmental Health Department <br />Payment <br />Received By <br />if APPLICANT 1$ 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 ENVIRONMEN1 AL HEALTH <br />Of PAR IMLNI as soon as it is available and at the same time It Is provided to me or my representative.______________________________________________ <br />ZIPState <br />Type of Service <br />Requested <br />Comments <br />□ Architect <br />■^-Application for <br />Operating Permit <br />If mobile food truck or <br />pumper truck <br />^Confirmation » 2.^ 5 <br />New Facility <br />71P <br />Accepted By <br />PE VoOl <br />M \ <br />First Name, . 0 <br />rveX/\x\l <br />Phone - Phone Email <br />License Plate Number^ATAlgg- <br />Application Form <br />Si,e{W Vd ' <br />APN 'Supervisor District <br />If contractor. Indicate type and license number <br />i o 2026 <br />-----------------------------— ~ LA“mnQ^?Al>ltv <br />BILUNG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all 'iRW»d/'^,(^§ct <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 />1° Iso 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 />Assigned To .____LAr\Y^<xres <br />Fee feoS.