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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />City ZIP Z <br />APN <br />E Change of Owner Repairs or Remodel Other Consultation <br />License Plate Number VIN <br /> Contractor Architect Property Owner Billing Party Facility Owner Facility Contact <br /> Contractor Architect(□•'facility Owner Property Owner Facility Contact Billing Party <br />If contractor, indicate type and license numberLast name <br />ZIPState(A <br /> Contractor Architect Property Owner Facility Owner Billing Party <br />If contractor, indicate type and license number <br />Email <br /> Architect Contractor Property Owner Facility Owner Billing Party <br />Last nameFirst Name <br />ZIPStateCityAddress <br />AUG 0 1 2)2^EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER <br />Title <br />[tec <br />1 <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 />ZIP _ <br />Site Address <br />If contractor, indicate type and licensRAV^^El IT <br />RECEIVED <br />Type of Service <br />Requested <br />Comments <br />______________- —------------------------------ -SAhUQAQUIN-GOUNTY <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all /^N T <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified onlhif <br />form. <br />I also certify that I have prepared this application and that the wo; <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />□Property /^ysiNESSOwro^ <br /> Facility Contact <br />Supervisor District <br />is application and that the woriHn'be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />First Name <br />Add,esU <br />PhonePhone n <br />I. C(A> <br /> Facility Contact <br />Application Form <br />Pincrwu <br />------------eTv’-------- <br />Last name » i <br />fl f'*/}£&>[(. <br /> Cash <br />State <br />State <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 />DEPART ME NT as soon as it is available and at the same time it is provided to me or my representative._____________________________________________ <br />i'irk! <br />■y 1^^173' <br /> Check « <br />Sidps <br />Address^ <br />Phone . AJ Phone <br />^Confirmation ff /