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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />State <br /> Repairs or Remodel Consultation Change of Owner Other <br /> Facility Owner Facility Contact Property Owner Contractor Architect <br /> Property Owner Contractor Architect Billing Party Facility Owner Facility Contact <br />If contractor, indicate type and license number <br />City <br />g V-A-x? <br /> Property Owner Contractor Architect Facility Owner Facility Contact Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />State ZIPCityAddress <br />EmailPhonePhone <br /> Contractor Architect Property Owner Facility Contact Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />State ZIPCityAddress <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER <br />Title <br />7Y <br />Linked FA IDAccepted By <br />Date <br /> Cash <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 />AoA U-C <br />VIN <br />ooo'^A <br />Z!P <br />Type of Service <br />Requested <br />Comments <br />Supervisor District <br />First Name <br />V^yyC\\\ \ <br />Address <br />Phone sss-) <br />License Plate Number <br /> Billing Party <br />Sifconfirmation ft <br />Phone <br />ZIP <br />JELSxMq. <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Or< <br />Standards, STATE and FEDERAlJ^ws. <br />APPLICANT’S SIGNATURE: L^1- <br />Facility Name <br />Site Address <br />APN <br />$ IM <br /> Check « <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 addreW^ra-^ the <br />release of any and all results, geotechnical data and/or environmental/slte assessment information to the SAN JOAQUIN COUNTY ENVIRONffi#^ Y <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />s,atp <br />Last name <br />Email <br />- <br />Received By| <br />Fee fl W