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New Facility OJ Exiting Fadlrt/ <br />LU <br />APN <br />^Change of Owner Other Repair? or Remodel ConMiltalion <br />VIN <br /> Architect Contractor Property OwnerO Fadlrty Contact <br /> Architect Contractor Billing Party Property Owner^Facility Owner Facility Contact <br />If contractor, indicate type and license number <br />ZIPState <br />fr/ryn <br /> Architect Contractor Property Owner Facility Owner <br />If contractor, indicate type and license numberLast namefirst Name <br />ZIPStateCityAddress <br />EmailPhonePhone <br /> Contractor Property Owner Facility Contact Facility Owner Billing Party <br />last nameFirst Name <br />StateCityAddress <br />EmailPhonePhone <br />Accepted By <br />FeePEDate <br /> Check « Cash <br />HevOZ/lO/ZOZ^ <br />C:( <br />Title <br />J-e <br />City <br />if mobile food truck or <br />pumper truck <br />Contact Types <br />required <br /> Application for <br />Operating Permit <br />San Joaquin County Environmental Health Department <br />Application Form \ S ^5 <br />in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />g-l |q / 2c~2-6 <br />Type of Servlco <br />Requested <br />Comments <br />| Billing Party <br />Assigned To . <br />I Adllty Name <br />ZIPState <br />j Facility Owner <br />ck or I license Plate Number <br />F irst Name <br />Address <br />^46 Fc^- <br />TOCIM <br /> Billing Party <br />— >,0^ PoVros .Site Address <br />Ws € ST , <br />Supervisor District <br />Linked FA ID. <br />EAOOO31HI <br />Record Nun.tSR. 25012^9 <br />Confirmation tt *£>8 5 <br />Last name <br />/\q( 1/1 <br />I Email <br /> Facility Contact <br />Cnv -r- <br />it l indicate type aj <br />recEiVed <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledg’e'Tn^FH ^PARr^' <br />speafic ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as dent <br />form. <br />I also certify that I have prepared this application and that the work to be performed will be done i <br />Standards, STATE and FEDERAL laws f) f) J A <br />APPUCANTSSIGNATURE: _________g/f6UR. 7 DA'' <br />■^PROPERTY / BUSINESS OWNER OPERATOR /MANAGER OTHER AUTHORIZED AGLM <br />If APPLICANT is not the BILUNG 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, hereby authorue the <br />release of any and all results, geotechnical data and/or environmental/site assessment Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMDEI as soon as it Is available and at the same time it is provided to me or my representative. <br />Phone