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d New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form � Q <br /> Facility Name <br /> Site Add ess ,n� I 1 City State ZIP d S � <br /> APN Supervisor District <br /> Type of Service Application for ❑Consultation 1ZI Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Per <br /> Comments <br /> If mobile food truck or Tucense Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party CI Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor 7­4�hitect <br /> required <br /> Q Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner EI Contractor Q Architect <br /> First Name Last name If contractor,indicate type and license number <br /> --t--4J QI �� <br /> Address City State ZIP <br /> 61 q w +%) S'r C- Tru c y <br /> Phone Phone Email <br /> 923'�s7-60 el <br /> ❑Billing Party Q Facility Owner Ckfacility Contact Q Property Owner ❑Contractor C]Architect <br /> First Name Last name if contractor,indicate type and license number <br /> J W a 01 ' V��WgI14 of j}� <br /> Address p City State ZIP <br /> (N i— 1 '� t C C <br /> Phone �. ' hone Email y <br /> 1.Z 2' t b2��`� ll)y�9'� n041 �L Nl <br /> Q Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ©Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State RED <br /> Phone Phone Email MAY <br /> r'H! 1 <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,ac t46 d or project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this projector activity will be billed t '1* RQ*J fl �s�cJJ i ed on this <br /> �ULTH DepAR 2 <br /> form. rr��{,��❑ <br /> 1 also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN CO <br /> LINTf47inance Codes, <br /> Standards,STATE and FED91V laws. <br /> APPLICANT'S SIGNATURE DATE:, <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER Cl OTHER AUTHORfZED AGENT <br /> Title <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 /> 1 <br /> Accepted B A ne`dNTo � Linked FA 1D <br /> Date. ! PE Fee I of Re 012-1.0 <br /> Numbe }�❑Cash Q Checktt Confirmation# -]�/NQq4—1� to <br /> Payment <br /> c/ v/ �'1� i Received By� <br /> Rev 07/10/2024 <br />