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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 <br />APN <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />License Plate Number VIN <br />□ Billing Party □ Facility Owner □ Property Owner □ Contractor □ Architect <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City ZIPS7~ <br />Email <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State <br />Phone Phone Email <br />□ Contractor□ Facility Contact □ Property Owner□ Billing Party □ Facility Owner <br />First Name Last name <br />StateAddressCity <br />EmailPhonePhone <br />DATE: <br />□ OPERATOR/MANAGER □ OTHER AUTHORIZED AGENT □ PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAssigned ToAccepted By <br />-K <br />PE FeeDate <br />lb 03 <br />□ Check It□ Cash <br />Rev 07/10/2024 <br />f> <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 />ZIP <br />MM <br />Type of Service <br />Requested <br />Comments <br />~Phone <br />^^Confirmation it <br />FAoo r? I <br />Payment <br />Received By <br />State <br />c <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 FEDERAUlaws. n. <br />APPLICANT'S SIGNATURE: ( ^<31—---------DATE: O / <br />ajhd number <br />■ <br />Phone _ I i,w. <br />I ZIP <br />If contractor, indicatory <br />Supervisor District <br />□ Facility Contact <br />t1 <br />1^1 Zb