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□ New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />P,S <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 />■KJ. Billing Party [^Facility Owner [>3. Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license number <br />IrJi P <br />J <br />□ Facility Owner □ Property Owner □ Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />kcation ani the worl <br />DATE: <br />□ PROPERTY / BUSINESS OWNER □ OTHER AUTHORIZED AGENT <br />Title <br />□ Check H <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />□ Application for <br />Operating Permit <br />City <br />ie performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />City State <br />CA <br />ZIP <br />^286 <br />ZIPState <br />CA <br />S. Existing Facility <br />Fee ©a) <br />nc 1 rr a <br />Type of Service <br />Requested <br />Comments <br />V <br />Site Address I <br />/ 4^) N w e_r <br />APN Supervisor District <br />.Vic c~4~' <br />Phone <br />Linked FA ID <br />Record Number <br />SP, 2.50'248 <br />Assigned To <br />fm,- <br />□ Confirmation it <br />Idress, nW^hy/OuJiorize tmAx <br />^J^entaWal^ <br />Bor <br />Email <br />□ Facility Contact <br />Qtyin'. | y t 0 <br />□ Contractor <br />Address <br />Phone <br />□ Billing Party <br />Accepted By <br />C. <br />PE <br />\<p(D2dZ^/3Ia5 <br />IflCash^/T^x--- <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-thjs <br />Standards, STATE and FEDE^^L laytfs. . <br />APPLICANT'S SIGNATURE: -7^-''' <br />□ OPERATOR/MANAGER <br />Last name <br />X"d\y^ry <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 address, nw^byyaujjionze t..v <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY Ewt^ONMENTAT Kt <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.. Q