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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />State <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 /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />State CA <br />Email <br /> Billing Party Facility Owner Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address State ZIPCity <br />Phone Phone Email <br /> Property Owner Contractor Architect Billing Party Facility Owner Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />ZIPAddressCityState <br />Phone Phone Email <br />work to <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAccepted By <br />Date <br /> Cash Check tt <br />Rev 07/10/2024 <br />2*5 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <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- <br />Standards, STATE and FEDERAL la <br />APPLICANT'S SIGNATURE: X <br /> Application for <br />Operating Permit <br />'ii Qi fyh'h <br />PE 1 .. <br />I <br />tprjp^ aimer <br />Type of Service <br />Requested <br />Comments <br />Application Form <br />City i Z-W-~ <br />Payment <br />Received By <br /> Contractor <br />■performed will be done in accordance with all SAN JOAQUIN COU; <br />____________ DATE: AZyCZr <br />iry^^inance Codes, <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required °EC 1 I 2025 <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above siteSj^y^reby authorize the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENV^^^LffMWJN WbNTY <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.______________________HFai <br />First Nam^) <br />^y/A e- f /XA4 ro M <br />"application and <br />Site Address ,s____L- KA <br />Supervisor District <br />Assigned To f ■» ’ ♦— j <br />671^/ r^ihknd <br />[^Confirmation ti '^{