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Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address <br /> Consultation Chance of Owner Repairs or Remodel Other <br />VIN <br /> Contractor Architect Facility Contact Property Owner Billing Party Facility Owner <br />j^aclllty ContactJ^acillly Owner^fuillinR Party Contractor Architect Property Owner <br />If contractor, Indicate type and license number <br />state <br /> Contractor Architect Property Owner Facility Owner Facility Contact Billing Party <br />if contractor, Indicate type and license number <br />State <br />Phone <br /> Architect Contractor Facility Owner Property Owner Billing Party Facility Contact <br />If contractor, Indicate type and license numberLast nameFirst Name <br />ZIPCityStateAddress <br />EmailPhonePhone <br />DATE: <br />OTHER AUTHORIZED AGENT PROPERTY/ BUSINESS OWNER <br />Linked FA IDAssigned To <br />Fee <br />Rev 07/10/2024 <br />Phone Email ♦ / <br />Contact Types <br />required <br />,t name <br />AL'-tADAJi <br />Last name <br />J^New Facility <br />Application Form <br /> n-| <br />144^ vc,tY <br />Supervisor District » <br />5“bA- <br />Flnp.Ve&M <br />Address <br />ZIP°I <br />-px k <br />$5&t; <br />^Confirmation « 'Zd? <br />^Application for <br />'Operating Permit <br />License Plate Number <br />APN <br />2121-200- <br />Type of Service <br />Requested <br />Comments . <br />If mobile food truck or <br />pumper truck <br />City <br />___________piope^ro <br />/tfazsHopv-n LpA^>E>elb He4- <br />5^3 <br />First Name <br />‘sr <br />^>r^77'Otl4- <br />PE Up OI <br /> Check # <br />lerformed will be done In accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />7/^D/■2.G■ <br />AzcHlT^crf^ <br />Tl,le <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, herein f <br />release of any and all results, geotechnical data and/or envlronmental/slte assessment Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEATTlf'^’^ <br />DEPARTMENT as soon as It Is available and at the same time It Is provided to me or my representative.^U(j f) n \ <br />^6^ S <br />Record Number Th <br />Payment . <br />Received By^A-^ <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 IIEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as Identified on this <br />form, J <br />I also certify that I have prepared this application andRh: <br />Standards, STATE and FEDERAL laws. /I L <br />APPLICANT'S SIGNATURE: jff <br />~ OPERATOR / MANAGER <br />Accepted By^ <br />--------- <br /> Cash <br />the WbrJ