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Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />®iBilling Party [^Facility Owner S'facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />^£^10 <br />Phone <br />[^Facility Owner Property Owner Contractor ArchitectM Billing Party <br />If contractor, indicate type and license number <br />% <br />Email <br /> Architect Contractor Property Owner Facility Contact Billing Party Facility Owner <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPStateCityAddress <br />EmailPhone <br /> OTHER AUTHORIZED AGENT <br />Title <br />Accepted By <br /> Checks Cash <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br /> Application for <br />Operating Permit <br />Payment <br />Received By <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 />Date <br />3-3I-3G <br />Type of Service <br />Requested <br />Comments <br />Email <br />5/Facility Contact <br />LajLname <br />[Ko: <br />Phone <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 preofiredjlhis application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />APPUCANT'S SIGNATURE: DATE: f <br /> PROPERTY / BUSINESS OWNER OPERATOR /TCiANAGER <br />V 'idcii Pe^ra z a <br />PE itpoa <br />State^ <br />“''vNa“ Ixo ______ <br />% h) • jV-SUiW) Ave <br />Supervisor District <br />First Name .. <br />___ <br />Address ’ . / <br />Phone iPhone <br />State <br />I Fa......... <br />(Site Address | <br />First Name . 1 <br />of <br />Phone <br />o 9I' ^66 c/ <br />Last name <br />V City. & I <br />l(JUC <br />Linked FA ID <br />F7\ 000X059- <br />Record Number <br />Confirmation « ^202^^ <br />Assigned To . <br />L H di ci 'B&ker <br />_________