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l/k Existing Facility□ New Facility <br />San Joaquin County Environmental Health Department <br />City. <br />Supervisor District <br />^Change of Owner□ Consultation □ Repairs or Remodel □ Other <br />License Plate Number VIN <br />□ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect□ Billing Party <br />-<3 Billing Party □ Property Owner □ Contractor□ Facility Owner □ Facility Contact □ Architect <br />If contractor, indicate type and license number.7. <br />. c g <br />□ Facility Contact □ Property Owner □ Contractor □ Architect□ Billing Party □ Facility Owner <br />If contractor, indicate type and license numberFirst Name Last name <br />City StateAddress <br />EmailPhonePhone <br />□ Property Owner □ Contractor□ Facility Contact□ Facility Owner□ Billing Party <br />Last nameFirst Name <br />City StateAddress <br />Phone EmailPhone <br />Id that <br />DATE: <br />□ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGERPROPERTY / BUSINESS OWNER <br />Title <br />lirtr FeePE <br />□ 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 />ZIPCity <br />‘7" <br />Type of Service <br />Requested <br />Comments <br />zipState <br />ifk to be performed will be done in accordance with all SA‘N JOAQUIN COUNTY Ordinance Codes, <br />V/26)/ <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 />ini <br /> '^Confirmation # <br />EmailZ <br />Application Form <br />Willo <br />Site Address <br />3^00 Mxglec 06/2. <br />APN <br />State <br />First Name <br />Address <br />Phone . Phone <br />If contractor, indica^tvftj^^ nc« <br />Accepted By —4^ ff <br />□ Cash <br />ZIP <br />7® Architect ***^- <br />J _ Q 202R <br />license numser <br />BILLING ACKNOWLEDGEMENT: I, the undersignedjU-operty or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT//urly 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 appliCjiTii <br />Standards, STATE and FEDERAL <br />APPLICANT’S SIGNATURE: ----