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Existing Facility New Facility <br />I <br />San Joaquin County Environmental Health Department <br />Application FormI <br />APN <br /> Change of Owner Repairs or Remodel Other Consultation <br />License Plate Number VIN <br /> Facility Owner Billing Party Facility Contact Property Owner Contractor Architect <br />©facility Owner □•'Facility ContactQuilling Party Contractor Architect Property Owner <br />If contractor, indicate type and license numberL^t name <br />tunnvi <br />Phone <br />){l Property Owner Architect Contractor Facility Owner Facility Contact Billing Party <br />If contractor, indicate type and license number <br />Phone <br /> Architect Property Owner Facility Owner Facility Contact Billing Party <br />If contractor, Indicate type and license numberFirst Name Last name <br />Cfose- <br />DATE: <br />NtlPROPERTY / BUSINESS OWNER OI KER AUTHORIZED AGENT OPERATOR/MANAGER <br />Assigned To <br />Fee <br /> Check # Cash <br />Rev 07/10/2024 <br />I <br />Phone <br />I <br />I <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />■%! Application for <br />Operating Permit <br />Email <br />City <br />Trzicq. <br />Address <br />fcCO Bel monk l_/i <br />Phone <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 <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMEN’ <br />DEPARTMENT as soon as it is available and at the same time it Is provided to me or my representative.____________________________________ <br />City <br />City <br />Email <br />ZIP <br />RS 2-ll <br />ZIP <br />.milk <br />ZIP <br />Date <br />State <br />oA <br />Last name <br />State <br />yi_Contractor <br />State <br />Type of Service <br />Requested <br />Comments <br />First Name <br />_______________ <br />Address <br />Sfrr eek <br />Phone <br />263“WO -'?'</</3 <br />Payment <br />Received By <br />State <br />CA <br />property located at the above site addre^^d^ty^^^^J^^^ <br />Accepted By, . <br />( <L q <br />ZIP <br />RS-3 77 <br />Facility Name <br />_____Ths-______________ <br />Site Address <br />32-Q1 VJ-feoTjcumn KolYb/. SteAloQ <br />I Supervisor District <br />s <br />(2 Confirmation « O( <br />City <br />T^< <br />First Nama^ <br />___________________________ <br />Addressms-ui. omw (M. <br />Phone <br />Email <br />ZSte/urgb a ^417 /«co _J____________ _____________ <br />^ILUNGACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or ^oject <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified <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 Ordii^^|«hi^T^ <br />Standards, STATE and FEDERAL laws. -»/ ./■>» <br />APPLICANT'S SIGNATURE: DATE: ----'I Ml *'&----------- ■ <br />-------^JOAr. 4 0?6 <br />■ ^^CC//4