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6^ Existing Facility□ New Facility <br />San Joaquin County Environmental Health Department <br />□ Consultation □ Repairs or Remodel □ Other <br />License Plate Number VIN <br />□ Contractor□ Facility Contact□ Billing Party □ Facility Owner □ Property Owner □ Architect <br />✓ZTsilling Party □ Facility Owner □ Facility Contact □ Contractor □ Architect <br />If contractor, indicate type and license number <br />Email <br />O rn <br />□ Property Owner □ Contractor □ Architect□ Billing Party □ Facility Owner □ Facility Contact <br />Last name If contractor, indicate type and license numberFirst Name <br />City State ZIPAddress <br />EmailPhonePhone <br />□ Facility Contact □ Property Owner□ Billing Party □ Facility Owner <br />Last nameFirst Name <br />Address City <br />EmailPhonePhone <br />^PROPERTY / BUSINESS OWNER □ OPERATOR / MANAGER <br />Title <br />Accepted B' <br />PE <br />infirmation#□ Check # <br /> <br />Rev 07/10/2024 <br />5 <br />J-Ml 1^ <br />2J7- <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 />□ Application for <br />Operating Permit <br />■work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Y s'_________________ DATE: A <br />□ OTHER AUTHORIZED AGENT <br />ZIPState c <br />Type of Service <br />Requested <br />Comments <br />X__________ <br />^ZfChange of Owner <br />Application Form <br />Wa~lZ <br />City^ ~ <br />ll-y^ <br />Supervisor District <br />State ZIP <br />73?? 76 <br />Payment <br />j Received By <br />’WT 11.7 <br />Site Address <br />MOO UP <br />APN <br />11^1 <br />First Name <br />Address <br />MOO <br />Phone <br /><309^07/3166 <br />^3(2^ <br />□ Cash <br />City <br />□ Property Owner <br />_____ <br />Phone <br />□ Contractor*4^QJ* <br />___/|Z£E)_______ <br />If contractdi’Afwicafle^ype and license number <br />- <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 appUj <br />Standards, STATE and FEDERM laws.^X* <br />APPLICANT’S SIGNATURE: X y