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Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />State ZIP <br /><G 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 />^S^illing Party J3-Fmdtity Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />City,State <br />Efpail <br /> Facility Owner Facility Contact Contractor 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 />DATE: <br /> OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER OPERATOR/MANAGER <br />Title <br />Linked FA ID <br />Date <br />Rev 07/10/2024 <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 />Cash <br />Type of Service <br />Requested <br />Comments <br /> Billing Party <br /> Check it <br />□Application for <br />/Operating Permit <br />If mobile food truck or <br />pumper truck <br /> Application Form <br />kn-2- EriEt <br />Supervisor District <br />Address <br />Accepten/y^tp <br />Ci,i4W^ <br />New Facility <br />Payment , <br />Received Bl <br />Assigned Tq <br />Fee ,. , <br /> Confirmation tt <br />- - <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that al!iiwfig^Aor 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 withall SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDER-WJaws^X") / / —7 / 72 ( <br />APPLICANT'S SIGNATURE: 7Z , DATE: <br />If contractor, indicate <br />SAN '^, [?'‘202b <br />________ ________z'p^S337 <br /> Property Owner <br />Site Address _ / <br />APN