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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />^Facility ContactFacility OwnerBilling Party Property Owner Contractor Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address <br /> Facility Owner Contractor Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address City State ZIP <br />Phone Phone Email <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor <br />First Name Last name <br />Address StateCity <br />Phone Phone Email <br />Bi <br />DATE:- <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAssigned To F.5 <br /> Check tt Cash <br />Rev 07/10/2024 <br />ESI <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 />Payment <br />Received By <br />Date <br />\-(o-Q.b <br />statt?A <br />Type of Service <br />Requested <br />Comments <br />City <br /> Billing Party <br />_____ FAW7lk>l <br />Record Number <br />^Confirmation « <br />h/A/ir? <br /> Facility Contact Property Owner <br />G i q't <br /> Application Form <br />fdgMC-^ tf0( aroject <br />y business av 4f^^ied on this <br />•• • JOAQUIN COUNTY Ordinance Codes, <br />I / b <br />Addfe7i/r^ iv <br />Supervisor District <br />Architect <br />If contractor, indicatfw/^'afid lirenC*j^imkpr <br />C. <br />PF i <br />v/Or <br />1111 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowlec <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business' <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 JO, <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: _______