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Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address City State ZIP <br />APN <br /> Change of Owner Repairs or Remodel Other <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />1^1 Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />State <br />Email <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Email <br /> Contractor Architect Billing Party Facility Owner Facility Contact Property Owner <br />If contractor, indicate type and license numberFirst Name Last name <br />City ZIPAddressState <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER JAN 13 2(26Title <br />Linked FA IDAssigned ToAccepted By Rut <br />Date PE <br /> Confirmation II Check « <br />Rev 07/10/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <br />'AL <br />HEALTHDEPARTfaENT <br />Phone <br />^09-^^ 77- <br />^Billing Party <br />^Consultation <br />Application Form <br />Type of Service <br />Requested <br />Comments <br />3/c/ E AM <br />Supervisor District <br />Phoner- i Phone <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, IlJNTY <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENEWVIRKDiNMEN AL <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />Last name , j <br />Retprd Number_S^2AQn^L—__ <br />Payment <br />Received By CaX/ <br />z,fA — <br />05> <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 />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 OrWiYMENT <br />APPLICANT'S SIGNATURE: (2 DATE: / ] J2^Z2^RECEIVED <br />First Name ; <br />____Fd-bLDLa.._____ <br />Address r .. <br />Phone <br />Fee4