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e� <br /> ❑ New Facility IV Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name f <br /> �t 6 1 ►-,, G, b9A 3r stuI <br /> Site Address C + State CA ZIP q�ZR <br /> zZ r �Gvd• I za <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner C7 Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> Vi�liL( <br /> If ma e food truck or Licen a Plate Number VIN <br /> pumper truck <br /> Contact Types 17 Billing Party 1 1]Fadlity Owner ❑Facility Contact ❑Property Ownerfl ElContractor El Architect <br /> required <br /> V'Silling Party ❑Facility Owner ❑Farility Contact ❑Property Owner ❑Contractor ❑Architect <br /> d T (r o-tA <br /> First Name V Last n e If contractor,Indicate type and license number <br /> � I'm1Ci Ao r LE <br /> A . 1 <br /> �dL33 QI v Zt .> tY C 't°n StateCA ZIPL3t7)-0T <br /> Phone Phone Email <br /> D Billing Party ❑Facility Owner ❑Facility Contact 0 Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address i City State ZIP <br /> i <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor REC tect <br /> First Name Last name If contractor,irl�iyya ttye and licenssee number <br /> Address City State ZIP <br /> SAN JOAQUJ COU <br /> Nry <br /> Phone Phone Email EgLT rAL <br /> H')EPA RTMeN <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 hourty 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 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. <br /> APPLICANrs SIGNATURE: DATE: 3� 6 / 20 L <br /> 0 PROPERTY/BUSINESS OWNER 'OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> T'itfe <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator ofthe property located at the above site address,hereby authorize the <br /> release of any and all results,geotechnfcal 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 some time it is provided to me or my representative. <br /> Accepted Assigned To �� In Linked FA ID <br /> bate PE � Fee f Record Numb �^ <br /> P;,7 m t <br /> WW <br /> LL Cash ❑check Ii Confirmation# 0��j (,(/ Received By <br /> Rev 07/10/2024 PIZ 0 1�0 0132(0 <br />