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s <br />Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address City State ZIPCP\95 m <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />^Billing Party [^Facility Owner H'Facility Contact Property Owner Contractor Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address State ZIP 9 5 337cn <br />- Phone <br />U 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 />Phone Phone Email <br /> Property Owner Contractor Architect Billing Party Facility Owner Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />City State ZIPAddress <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER JUL 2 9 2025Title <br />PE <br /> Check W Cash <br />Rev 07/10/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <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^AM^JQSMjWM'COU'HW <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. HEALTH DEPARTMENT <br />Type of Service <br />Requested <br />Comments <br />Lit <br />Accepted By <br />C- <br />DateT-iz-qt-z-s <br />Received <br />Linked FA ID <br />Record Number <br />City <br />___________Application Form <br />In^ctn CftfE L-Q^a <br />19 8 In M <br />Supervisor District <br />iv\ cvnfec & <br />te i- <br />Confirmation H <br />Assigned To <br />FYcnGiSto P- <br />Fee <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 O <br />Standards, STATE and FEDERAL laws. I) /// 0'7—A — ' <br />APPLICANT'S SIGNATURE: [ DATE: ' <br />Payment i I I <br />Received By