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5 <br />□ New Facility □ Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />APN <br />□ Change of Owner □ Repairs or Remodel □ Other□ Consultation <br />VIN <br />□ Facility Contact □ Property Owner □ Contractor □ Architect□ Facility Owner <br />□ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect□ Billing Party <br />If contractor, indicate type and license number <br />I <br />□ Facility Owner □ Facility Contact □ 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 <br />First Name Last name <br />Address ZIPCity <br />Phone Phone Email <br />DATE: <br />□ PROPERTY / BUSINESS OWNER □ OPERATOR/MANAGER □ OTHER AUTHORIZED AGENT <br />Title <br />Linked FA IDAccepted By Assigned To <br />Fee <br />174, (T/ <br />Rev 07/10/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <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 ENVIRONMENI AL HEAL IH <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 />State <br />o <br />State <br />ZIP <br />City <br />Type of Service <br />Requested <br />Comments <br />PhonePhone ' ‘ <br />□ Billing Party <br />License Plate Number <br />□ Billing Party <br />Email <br />□ Property Owner <br />City <br />ZIP <br />4^^ <br />Facility Name <br />_____________Luf__yaa<.>,x____ <br />Site Addr^s ’ ' .'3ss // A/. J <br />.-rvisor District ' <br />PE <br />□ Check « <br />Date I <br />□ Cash Confirmation If <br />First Name <br />Address <br />Last name <br />---------------- <br />□ Contraafr^^/y* Arc^'tect <br />_____________________________If contractor, indiAC/L*>u.na license number <br />. <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledg^VjSt 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 FEDERAL,!^^. » <br />APPLICANT'S SIGNATURE: \ \ - DATE: Z| J /