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{ <br />New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br />VIN /a// £> // <br /> Property Owner Contractor Billing Party Facility Owner Facility Contact Architect <br /> Facility Owner Facility Contact Property Owner Contractor Architect Billing Party <br />If contractor, indicate type and license number <br />EmailPhone <br />■ T <br /> Property Owner Contractor Architect Billing Party Facility Owner Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />State ZIPAddressCity <br />Phone EmailPhone <br /> Contractor Architect Facility Contact Property Owner Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />City State ZIPAddress <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAccepted By <br />Rev 06/12/2024 <br />Contact Types <br />required <br /> Application for <br />Operating Permit <br />QC) <br /> OPERATOR / MANAGER <br />Type of Service <br />Requested <br />Comments <br />If mobile food truck or <br />pumper truck <br />Licens^umber^^ ? <br />City/ <br />ecH/Vf0 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Cfn <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby^rTortfefflhe <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH CU, 'J <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.^OAQi i,. . <br />State . <br />C4Z <br />FirstName <br />Phone <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 Ordinance Codes, <br />Standards, STATE and FEDERAL laws.^^.Z^i Ci /J& <br />APPLICANT'S SIGNATURE: CC sA '' /\) \ DATE: / f / & . <br />Ppp <br />#537. 0® <br />Zl>’^ <? <br />Date, , Cjlie>l2,3 <br />Assigned To <br />prctn O/SGC) A-- <br />Record Number , <br />State/Q z <br />yeP-A a <br />Application Form <br />Supervisor District <br />Site Address <br />N