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New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />State ZIPc A <br />APN <br /> Change of Owner Repairs or Remodel Other <br />VIN <br /> Billing Party Facility Contact Property Owner Contractor Architect <br /> Billing P| Contractor Architect Facility Contact Property Owner <br />If contractor, indicate type and license numberFirst Name <br />>0^7. <br /> Architect Property Owner Contractor Facility Owner Billing Party <br />If contractor, indicate type and license numberFirst Name Last name <br />ZIPCityStateAddress <br />Phone EmailPhone <br /> Contractor Property Owner Billing Party Facility Owner Facility Contact <br />Last nameFirst Name <br />77StateCityAddress <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER <br />Title <br />Linked PAIDAssigned ToAccepted By <br />Rec< <br />yConfirmation# / g Check # Cash <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <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 />Date <br />0^ - o H -2Z <br />^^onsultation <br />Email <br />Type of Service <br />Requested <br />Comments <br />Payment / ///T- <br />Received ByC-f% Lz <br />Lasjmame . <br />[^Existing Facility <br />7JU <br /> Facility Contact <br /> Application for <br />Operating Permit <br />License Plate Number <br /> Facility Owner <br />J Facility Owner <br />Sr—— <br />s,ateo/\ <br />ci v <br />PEltoJ <br />If contractor, indicate type and licer <br />Oil Dn —?026 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/orprU^F/Vy <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 laws. ' I /O / <br />APPLICANT'S SIGNATURE: —J ( Y V 1 / <br />. g A <br />Fee <br />_^T3___________ <br />Facility Name— i J I <br />_____G /l u / v CY&-C YL'Z <br />Site Address 1 A <br />Supervisor District <br />"-/S s a