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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />citv State <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br /> Billing Party Facility Contact Property Owner Contractor Architect <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <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 /> Billing Party Facility Owner Facility Contact Property Owner Contractor <br />First Name If contractor, indicate t'Last name <br />Address City State <br />Phone Phone Email <br />DATE: <br /> PROPERTY / BUSINESS OWNER OPERATOR / MANAGER OTHER AUTHORIZED AGENT <br />Title <br />A< <br />PE Fee <br />LioOcS <br /> Check II <br />Rev 07/10/2024 <br />Contact Types <br />required <br />Payment <br />Received By <br />ZIP <br />Phone <br />VIN <br />I <br />Type of Service <br />Requested <br />Comments <br />Linked FA ID <br />Record Number <br />SR.25<Z)//¥£> <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, hereby authorize the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />A5Si8<U^ <br />mL I <br /> 2025 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/wr^(Tct <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 laA/s. fl V'')| <br />APPLICANT'S SIGNATURE: ------- <br />Date . <br /> Cash <br />j»irst Name <br />Address <br />Ljjst name <br />:---------------------------1 <br />AZ. \A/i(g^AZ__Y/4/_____Phone Email Z • <br />r Staj <br />Application Form <br />Facility Name <br />ZZ/Z4Z7 S A/Z/Cbjgz; V/Ay <br />APN Supervisor District <br />5~— ‘x c| - z <9 5 <br />2P Confirmation it <br /> Application for <br />Operating Permit <br />If mobile food truck or I License Plate(?lumber <br />pumper truck| <br /> Facility Owner