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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address City State ZIP <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation L Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or Licenp Plate Number VIN <br /> pumper truck `!71 IMCL0062 1/4 Z4 -j'? <br /> Contact Types Q Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Fatuity Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Na�ie l- name �� If contractor,indicate type and license number <br /> /5 tT t <br /> Address City State ZIP <br /> c_ 4-) C A-1 9S zo -'- <br /> Phone Phone Email <br /> t`— t e <br /> ❑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 <br /> ❑Ming Party ❑Facility Owner ©Facility Contact ❑Property Owner ❑Contractor Ll Architect <br /> First Name Last name If cortractor,indNtg_ty a '+umber <br /> Address City State Z <br /> 10 <br /> Phone Phone Email SaN <br /> J11 <br /> D'4Q f <br /> 1 .!Ai' _ <br /> BULLING ACKNOWLEDGEMENT;I,the undersigned property or business owner,operator or authorized agent of same,ac gait'aYa refand or project <br /> specific ENVIRONMENTAL HEALWDEPARTNT hourly charges associated with this project or activity will be billed to me or my busires��yir�tiied an this <br /> form. <br /> 1 also certify that I have prepareion and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL <br /> APPLICANT'S SIGNATURE: DATE: <br /> ❑PROPERTY/BUSINESS 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 By Assigned To Linked FA ID <br /> Date PE Fee k} Record Number <br /> _ a t~71 �p2603161 <br /> ❑Cash ❑Check p onfirmation d U Payment <br /> Received By <br /> RevD7/10/20Z4 <br />