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'^Existing Facility Nev/Facility <br />I adlity Name <br />ZIPStateCity ^530 LiCASite Address LI <br />APN <br /> Other Repairs or Remodel^(.Change of Owner Consultation <br />VINlicense Plate Numberck or <br /> Architect Contractor Property Owner Facility Contact■ Facility Owner Billing Party <br /> Contractor Property Owner Facility Contact Billing Party <br />Last nameFirst Name <br />ZIPState I <br />ra>22. <br /> ArchitectO Contractor Property Owner Facility Contact Billing Party <br />If contractor, indicate type and license number <br />First Name <br />Phone <br /> Architect Contractor Property Owner Facility Contact Billing Party <br />If contractor, indicate type and license numberlast nameFirst Name <br />ZIPStateGtyAddress <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER0) PROPERTY / BUSINESS OWNER Title <br />V\ core’s <br />Date <br /> Check « Cash <br />Rev 07/10/202'1 <br />If mobile food truck qr, <br />pumper truck I <br />Contact Types <br />required <br /> Application for <br />Operating Permit <br />San Joaquin County Environmental Health Department <br />Application Form?2-o-s <br />ZIP Z— <br />Type of Service <br />Requested <br />Comments <br />linked f A ID <br />Payment <br />Received By <br />1 ;____ I <br />Phone EmailC) f Ch > <br />City <br />______/llOunfcii* MjuVC <br />State <br />Last name <br />_____ ____________________ <br />City <br />l )' Co <br />farnono _ <br />Supervisor District <br />Accepted By . <br />PE \\qo2. <br />Address . <br />//// ___ <br />I phone Email <br />Address,'/fa fa&hl <br />Phone <br />w______1 <br />Assigned To^ <br />If APPLICANT is not the BILUNG 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 />| □Architect <br />If contractor, indicate type and license number <br />^Confirmation ff 2-^ S \ fa <br />I [< Facility Owner <br />I Facility Owner <br />I Facility Owner <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 />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 />__________oak. —