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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address City�G C State C ,^ ZIP �5 3 O� <br /> A9534 S Chr;s r (l . <br /> APN Supervis District <br /> as3-Z3o-o6 gq <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ElRepairs or Remodel Other <br /> Requested Operating Permit <br /> Comments (5�5/v ZS \ <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types Billing Party ❑Facility Owner ❑Facility Contact ;rroperty Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party ❑Facility Owner ❑Facility Contact NProperty Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> vreno <br /> Address City State ZIP <br /> 78A 6? ��,r, ;rc�e -TTc,r- c ►� a s3 7-7 <br /> Phone Phone Email <br /> ( /U SS7-70 Jureno 696 tieko o.crv� <br /> ❑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 ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor 'test <br /> First Name Last name If contractor,indicate t tAC�num <br /> Address City State AZlpi 5������ <br /> Phone Phone Email E i QUIIy co <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge thaf-alfi ro'ect <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identifies his <br /> form. <br /> I also certify that I have prepared this applicatioa,-aid4hztlMe—w--or-rn>e performed will be done in accordance with all SANK JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and APPLICANT'S SIGNATURE: DATE: <br /> laws. DATE: OVth/1 l /Z 6 <br /> v <br /> I PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED 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,1,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 tome or my representative. <br /> Accepted By Assigned To ,� /� Linked FA ID <br /> Date �� PE Zoo 2 Fee m, 00 R cord Nu ber O I <br /> ❑Cash ❑Check# Confirmation# ZLF Payment <br /> Received BaV <br /> Rev 07/10/2024 744 <br /> -54^J <br />