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W New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> FacilRy Name j�L SPea�eo.S 1 GL , Oo <br /> Site Address` a City(IXTCO\G State Gt.de1013 <br /> APN G Supervisor District <br /> TypeofServke pllation for ❑Consultation ❑ChangeofOwner ❑Repalrsor Remher <br /> Requested OpeaUng Pemtil <br /> Comments <br /> I�EW EODY x RA t <br /> IF mobile food truck or License Plate Number VIN <br /> pumpertrudc <br /> Contact Types Billing Parry Wadity Owner ❑Facility Contact ❑Property Owner LQ Contractor ❑Architect <br /> required <br /> i <br /> Billing Party 01 acility Owner ❑Facility Contact ❑Property Owner 19-Contractor ❑Architect <br /> P <br /> First Name Last name If contractor,Indicate type and license number <br /> 6r n v <br /> ress ;10.r <br /> Add City State ZIP a <br /> z r t cotx- CA as3y <br /> Phone Phone Email <br /> �i- UAC ILo A;\.co <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contactor ❑Architect <br /> First Name Last name if contactor,indicate type and license number <br /> Address my State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Fa ty Owner ❑Facility Contact ❑Property Owner ❑Contactor ❑A <br /> ��+IENT <br /> First Name Last name If contactor,Indicate type and license <br /> Address city State 1 <br /> aqN JOgpU <br /> Phone Phone Email He;"; NMENTgL _ <br /> pEMRTMENi <br /> [specific <br /> I WNG ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project <br /> ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br /> rm. <br /> 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 /> andards,STATE and FEDERAL laws.PPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER IkOPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <br /> If APPUCANT 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 a$soon as It Is available and at the same time It is provided to me or my representative. <br /> Accepted By Assigned To Linked FA ID <br /> Date PE Fee Record Number <br /> I 1,1q AP2400}43 <br />