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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 5 T c2CA'^/5late ZIP <br />APN <br />□ Repairs or Remodel □ Other□ Consultation □ Change of Owner <br />License Plate Number VIN <br />□ Architect□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor <br />Billing Party □ Property Owner □ Contractor □ Architect□ Facility Owner □ Facility Contact <br />If contractor, indicate type and license number <br />State ZIPcA z i SZ <br />Email <br />□ Architect□ Contractor□ Facility Owner □ Facility Contact □ Property Owner□ Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />State ZIPAddressCity <br />EmailPhonePhone <br />Architect□ Facility Contact □ Property Owner□ Billing Party □ Facility Owner <br />Last nameFirst Name <br />Mat o 4 71CityStateAddress <br />EmailPhonePhone <br />DATE^xS. <br />□ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGER <br />Title <br />Linked FA IDAccepted By <br />IG? ot.PE <br />a <br />□ Confirmation it□ Check # <br />Rev 07/10/2024 <br />II <br />Standards, STATE and FEDEjRAUaws. <br />APPLICANT'S SIGNATURE: <br />A <br />^PROPERTY / BUSINESS OWNER <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />Application for <br />Operating Permit <br />- <br />O C^sh <br />Type of Service <br />Requested <br />Comments <br />Phone <br />First Name <br />A <br />Address <br />A4AKRFT & <br />Supervisor District <br />□ conw.pAYMENT’' <br />If contracense number <br />Phone <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^nd at the same time it is provided to me or my representative. <br />--------------------------------------Assigned T* <br />Fee ._ .n <br />Last namepc Aye I <br />City5 <br />2AN JOAQUIM CC UNTY <br />ENVIRONMENTAL <br />____________________________________________________________Health d^artment - -.....— <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDf^RALjaws. /j / Z2 (j^ <br />Record <br />Payment J .A-? <br />Received By c