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Existing Facility□ New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />APN <br />JK^Change of Owner □ Repairs or Remodel□ Consultation □ Other <br />License Plate Number VIN <br />U Facility Contact □ Contractor □ Architect□ Billing Party □ Facility Owner □ Property Owner <br />^E^Facility Contact{^Billing Party /^.Facility Owner □ Property Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license number <br />State PA <br />L <br />□ Contractor□ Property Owner □ Architect□ Facility Owner□ Billing Party <br />If contractor, indicate type and license numberFirst Name Last name <br />ZIPCityStateAddress <br />EmailPhonePhone <br />□ Property Owner □ Contractor□ Facility Contact□ Facility Owner□ Billing Party <br />First Name Last name <br />StateCityAddress <br />EmailPhonePhone <br />oq / ; 7-DATE: <br />□ OTHER AUTHORIZED AGENT <br />Title <br />F.F <br />□ Check il <br />Rev 07/10/2024 <br />E3F <br />□ Confirmation tl <br />If mobile food truck or <br />pumper truck <br />□ Application for <br />Operating Permit <br />Contact Types <br />required <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 />Type of Service <br />Requested <br />Comments <br />I75Cftd 0 i doCom <br />□ Facility Contact <br />Assigned To <br />' J* <br />(aj t f 1^ /1 <br />A 7 I Phone <br />Accepted By <br />Date . <br />^^Cash <br />If contractor, indicat^5E©p,(IV/E*'k4ipr <br />_____________________ _______________ H£/ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge thaTalfsfMtliUifp/VT’ject <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 COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws/7 ! J) <br />APPLICANT'S SIGNATURE^ <br />□ PROPERTY / BUSINESS OWNER OPERATOR / MANAGER <br />LiM PalfkV'Cx y/vevcricA <br />^37 E yosemi+e_____ <br />Supervisor District <br />PE\c>a)z <br />Linked FA IDAXW 252-53 <br />Record Number , _ <br />___________ <br />Payment A 1 <br />Received By \