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Existing Facility□ New Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address State ZIP c\53a.oeft <br />APN <br />^Change of Owner□ Consultation □ 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 □ Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license numberLast name <br />State <br />^fracility Owner□ Billing Party □ Contractor□ Property Owner □ Architect <br />If contractor, indicate type and license number <br />Phone <br />□ Contractor□ Billing Party □ Facility Owner □ Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br />irfoi <br />□ OPERATOR / MANAGER □ OTHER AUTHORIZED AGENT OPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAssigned ToAccepted By Vidal Pedraza Gehane Fahmy <br />PEDate 16028/19/25 <br />Payment 207104366 <br />Rev 06/12/2024 <br />Email <br />If mobile food truck or <br />pumper truck <br />□ Application for <br />Operating Permit <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 <br />Standards, STATE and FEDERAL lAvs. ) <br />APPLICANTS SIGNATURE: <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/slte 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 />Contact Types <br />required <br />ZIP <br />^533J <br />Last name jl 1 <br />Type of Service <br />Requested <br />Comments <br />Address <br />A237 '7c>?6aw <br />'Covty___________ <br />□ Property Owner <br />Application Form <br />Supervisor District <br />□ Facility Contact <br />First Name 1 A <br />__________________r—Phone Phone I Email ~ <br />___ <br />□ Facility Contact <br />Zl<q5337 <br />Address <br />9A37 <br />ied will be done in accordance wittf all SAN JOAQUIN COUNTY Ordinance Codes, <br />“V_____ DATE: 15/A&33 <br />LO <br />Record Number ,Fee jyg