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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br /> Other Repairs or Remodel Change of Owner Consultation <br />License Plate Number <br />La V fvi )gg I <br /> Property Owner Contractor Architect Billing Party Facility Owner <br /> Contractor Architect•^Facility Owner p<Facility Contact Property Ownerb/Billing Party <br />If contractor, indicate type and license number <br />State <br />^71 <br />Eriail /-)Phone <br /> Contractor Architect Facility Contact Facility Owner <br />If contractor, indicate type and license numberLast nameFirst Name <br />StateCityAddress <br />EmailPhonePhone <br /> Contractor Property Owner Facility Contact Facility Owner Billing Party <br />Last nameFirst Name <br />StateCityAddress <br />EmailPhonePhone <br />DATE: <br /> PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAssigned To~lAccepted By <br />PEDate <br /> Confirmation # Cash Check <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 />Payment <br />Received By <br />ZIP <br />Type of Service <br />Requested <br />Comments <br />Mi ^0 <br /> Property Oxtfner <br /> Facility Contact <br />Q <br />iwner <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 apptfaation and that the woi <br />Standards, STATE and FEDERAL laws, <br />APPLICANT'S SIGNATURE: ___________ <br /> OPERATOR/MANAGER <br />Site Address1^0 <br />APN <br />Record Number^ <br />->2-2- 72 <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 />State <br />Last name # <br />a <br />City <br />^17/ kzTd-rffij <br />Supervisor District <br />________________ <br />PAY^r <br />If contra^^rJ©w><y[je and license number <br />jation and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> OTHER AUTHORIZED AGENT _ <br />First Name <br />____m_______________ <br />■ Address^. . <br />Phone Phone <br />55^- AqqI- n7J?4 <br /> Billing Party