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5” <br />Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />Site Address Stati <br />APN <br />[JJ-CKange of Owner Consultation Repairs or Remodel Other <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br /> Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberLast name <br />Phone <br /> Property Owner Contractor Billing Party Facility Owner Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City ZIPState <br />Phone Phone Email <br /> Facility Contact Property Owner Billing Party Facility Owner <br />First Name Last name <br />Address City <br />Phone EmailPhone <br />SAN JOAQUIN COUNTY Ordinance Codes, <br />DATE: <br /> OPERATOR/MANAGER OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER <br />Title <br />Assigned To <br />1(102- <br /> Check N <br />Rev 07/10/2024 <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 />Id that the work to be performed will be done in accordance with <br />_____ <br />Payment <br />Received By <br />Type of Service <br />Requested <br />Comments <br />:ity <br /> Application for <br />Operating Permit <br />of- ouowr <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />is/silling Party <br />plicatmr^e^i <br />unteaFA'°W0^2-Q <br />Record Number <br />—_________________ <br />’^Confirmation H Q <br />Application Form <br />Supervisor District <br />WllA £ <5^ <br />fh°ne' <br /> Facility Contact <br />Da,ev2m' <br /> Cash <br /> Contractor <br />If contractor,number <br />st^ Jan 2 / <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that ai1Si«lmd/or project <br />specific ENVIRONMENTAL HEALTH DEPMTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br />form. I <br />I also certify that I have prepared <br />Standards, STATE and FEDERAL laws.. <br />APPLICANT'S SIGNATURE: _