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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Supervisor District <br /> Consultation Change of Owner Repairs or Remodel Other <br />License Plate Number VIN <br /> Property Owner <br /> Facility OwnerBilling Party Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />State <br />Phone Email <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />EmailPhonePhone <br /> Contractor Billing Party Facility Owner Facility Contact Property Owner <br />First Name Last name <br />Address City State <br />Phone Phone Email <br />i' <br />DATEf <br />(pt)THER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER OPERATOR/MANAGER <br />Linked FA IDAccepted B^ <br />PE <br /> Confirmation » <br />Rev 07/10/2024 <br />IKig <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <br />Record Number <br />Last name <br />/ <br />/ <br />/ <br />san <br /> Architect Facility Owner <br />If contractor, indicate type and licensed <br />W25- <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 />R. <7I I, p <br />Check tt <br />vidli) <br />First Name A <br />Low <br />Phone <br />it the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Title <br />City , <br />_____________________________________ <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 applicajj* <br />Standards, STATE and FEDERAL laws. <br />APPLICANVS SIGNATURE: ^ —----- <br />State . <br />I ContractorI Billing Party <br />c,tv SWo. <br />| Facility Contact <br />Date <br /> Cash <br />Facility Name Z^. A <br />70 u. <br />APN ' ’ TT~ <br />Type of Service <br />Requested <br />Comments <br />L3I 03 <br />Payment XiLAA- <br />Received By c-py Az