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New Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address City State <br />i C/A <br />APN <br />BfChange of Owner Consultation Repairs or Remodel Other <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />H Billing Party Ef Facility Owner □^Facility Contact Property Owner Contractor Architect <br />First Name Last name If contractor, indicate type and license numberWen5. <br />Address State <br />CA <br />Com <br /> Billing Party Facility Owner Property Owner 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 Contractor Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address City State ZIP <br />Phone Phone Email <br /> OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER OPERATOR/MANAGER <br />Title <br />11^ <br />Assigned ToAccepted By <br />/ <br /> Check # Cash <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 />Date <br />Phone <br />ZIP <br />^5^ <br />2025 <br />xize the <br />Type of Service <br />Requested <br />Comments <br />"S'i Jeer <br /> Facility Contact <br />c <br />Email <br />^Existing Facility <br />Phone <br />___________Application Form <br />Shermcin #(<?______ <br />6>I2 W LoJi Ave ste. lost <br />Supervisor District <br />C- <br />$ 2. <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 bejjerformed will be done in accordance with all SAN JOAQUIN COUN Codes, <br />Standards, STATE and FEDERAL laws. A . f n c Or* <br />>. APPLICANT'S SIGNATURE: __________K ‘ ___________________ DATE: ■ <br />City <br />Linked FA ID <br />FAg0a0c?<?4 <br />Record Number 5RS501550 <br />Payment / / / yl/ <br />Received By^/4///7) <br />^00 6 <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required j, <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site adqfj <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />Confirmation n 2-OtQ (j2 <br />TVa^ci^co <br />Feei <br />ZIP q 5340