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Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name Xiict The <br />State <br />Supervisor District <br />2g(Change of OwnerA Repairs or Remodel Other Consultation <br />License Plate Number VIN <br />.J^Facility ContactJ3 Facility Owner ArchitectJZf Billing Party Property Owner Contractor <br /> Contractor Architect^Billing Party ETFacility Owner B'Tacility Contact Property Owner <br />If contractor, Indicate type and license numberLast name <br />Address *5DT <br /> Contractor Property Owner Facility Contact Billing Party Facility Owner <br />If contractor, indicate typeLast nameFirst Name <br />StateCityAddress <br />Phone EmailPhone <br /> Contractor Property Owner Facility Contact Facility Owner Billing Party <br />Last nameFirst Name <br />ZIPStateCityAddress <br />EmailPhonePhone <br />(pf PROPERTY / BUSINESS OWN ER OTHER AUTHORIZED AGENT <br />Title <br />Linked FA IDAssigned ToAccepted By <br />Fee <br /> Check « Cash <br />Rev 07/10/2024 <br />I <br />I <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 />Citv <br />•"T <br />Phone <br />LjOS -b{ U’tf -m<> I i <br />ZIP <br />First Name <br />Type of Service <br />Requested <br />Comments <br />Site Address — <br />APN <br />I—\ Vacx/ es <br />PE <br />WoO'Z. <br />|2.r St- <br />Phone <br />Record Number <br />_____________ <br />'^(^Confirmation# 2-\ <br />CityT <br />Email . <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 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. U I i„l ■> L>APPLICANT'S SIGNATURE:DATE: ---------/..^L---------------------------------------- <br />[^OPERATOR/MANAGER <br /> Atthitect <br />If contractor. Indicate type and license nunrown^T’ <br />ZIPstateoA