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5 <br />□ New Facility 13 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />4 <br />□ Consultation J0£hange of Owner □ Repairs or Remodel □ Other <br />License Plate Number VIN <br />□ Billing Party □ Facility Owner 8 Facility Contact H Property Owner □ Contractor □ Architect <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license number <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Architect <br />First Name Last name <br />Address City <br />Phone Phone Email <br />DATE: <br />CyPROPERTY / BUSINESS OWNER H OTHER AUTHORIZED AGENT <br />C.<? <br />□ Check #□ Confirmation # <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 />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />□ Application for <br />Operating Permit <br />Email <br />SumsrantL- , <br />-----------^7^7 <br />Type of Service <br />Requested <br />Comments <br />ZIPSite Address <br />APN <br />pq |is)lC <br />Title <br />Assigned To <br />Fe7/7 <br />? ' Phone <br />I ^6 <br />If conttagtoA iljiicl^^pe and license number <br />_ Str__ _______ <br />— <br />State <br />•tastname^---------------- <br />Accepted By <br />C- <br />^Cash <br />Rev 07/10/2024 <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 apolication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standard^TATE and FEDERAL laws. Ml <br />□ OPERATOR / MANAGER <br />Supervisor District <br />City/ <br />COT)/ <br />PE <br />Linked FA ID <br />fi4gQ>ZS28l_________ <br />Record Number <br />SQ-2cSg>m-^-2-_________ <br />I Payment “ <br />Received By( A /