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□ New Facility □ Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address State CH <br />APN <br />□ Change of Owner□ Consultation □ Repairs or Remodel □ Other <br />□ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license numberLast name <br />State <br />Email <br />□ Billing Party □ Contractor□ Facility Contact □ Property Owner □ Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address City State ZIP <br />Phone Phone Email <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor <br />First Name Last name <br />Address City State <br />Phone EmailPhone <br />□ PROPERTY / BUSINESS OWNER □ OPERATOR/MANAGER <br />Title <br />Accepted By Linked FA IDAssigned To <br />PE <br />zfconfirmation M□ Cash □ Check H <br />Rev 07/10/2024 <br /> <br />□ OTHER AUTHORIZED AGENT <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <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 />QCfApplication for <br />Operating Permit <br />If contractor, indicate <br />34^ <br />02/^7/524. <br />Application Form <br />q/7 /' A 5 <br />\Wcq caaio <br />Supervisor District <br />Type of Service <br />Requested <br />Comments <br />I AX <br />cftionnse number <br />_________ <br />DalVio-Z-u> <br />□ Facility Owner <br />License Plate Number .7 P I <br />□ Billing Party <br />CiUt <br />Feefin4 ] J <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 ar activity will be billed to me or my business as identified on this <br />form, ,1 , <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 />Payment fl <br />Received By/ / <br />ZIP x