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sf Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Site Address StateSt c(\ <br />APN <br /> Other Change of Owner Repairs or Remodel Consultation <br />Q-f’roperty Owner Contractor ArchitectEl Billing Party Facility ContactFacility Owner <br />0 Billing Party Architect Property Owner Contractor Facility Contact <br />If contractor, indicate type and license number <br />l , tow. <br />□Property Owner Contractor Architect Billing Party Facility Owner <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPStateCityAddress <br />EmailPhonePhone <br /> Contractor Property Owner Facility Contact Facility Owner Billing Party <br />Last nameFirst Name <br />StateCityAddress ?02S <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER <br />Title <br />Assigned ToAccepted By <br />Fee <br />IT Confirmation # <br />Rev 07/10/2024 <br />I <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 HEALIH <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 />toinrAt fV <br />Phone I Phone <br />VIN <br />______ <br />BTacility Owner <br />License Plate Number <br />Type of Service <br />Requested <br />Comments <br />Email <br />NAt^^70y <br /> Facility Contact <br />pa/ <br />If mobile food truck or <br />pumper truck <br />Date . | <br />—a-___| \ ,-z— <br />Xcash(ii h <br />If contractor, indicate typCwndJkgr <br />___ <br />_________________________________________________________________________ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site anc$&nV$ect <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 COUNIY Ordinance Codes, <br />Standards, STATE and FEDERAtflaws, <br />APPLICANT'S SIGNATURE: DATE: —L----------- <br />^5 <br /> Check U <br />City <br />Last name <br />7So £ (Vhfr <br />Supervisor District <br />ZIP <br />First Name-. <br />Address <br />st ar <br />Rec°rdNum^ai?(W> <br />Payment <br />Received By <br />Z1P z