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^^Existing Facility□ New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />APN <br />^Change of Owner□ Consultation □ Repairs or Remodel <br />License Plate Number VIN <br />jS^Facility Owner□ Billing Party □ Facility Contact □ Contractor□ Property Owner <br />j^FfScility Owner □ Facility Contact □ Property Owner □ Contractor□ Billing Party <br />If contractor, indicate type and license numberLast name <br />□ Property Owner □ Architect□ Billing Party [^-•Facility Owner <br />If contractor, indicate type and license numberFirst Name <br />i <br />Phone 2? 0*7—Email <br /><?-6> <br />[^Facility Owner □ Property Owner □ Architect□ Facility Contact□ Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />Phone <br />DATE: <br />□ OPERATOR/MANAGER OTHER AUTHORIZED AGENT□ PROPERTY / BUSINESS OWNER <br />Fee <br />□ Confirmation tlCheck tt□ Cash <br />Rev 07/10/2024 <br />5 <br />7 <br />City <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />in i-r-f-rc / <br />T <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 />Email <br />City <br />--i\< '' <br />State <br />ZIP <br />Accepted B’ <br />Date <br />ZIP <br />Phone f „ <br />3o9-Vp7-yo2^, <br />ZIP <br />7^7% <br />State <br />State <br />- / <br />Type of Service <br />Requested <br />Comments <br />Address <br />/35~ Ia/ <br />Phone — <br />>1 | (X <br />□ Contractor <br />City <br />1 <br />PE <br />IGOZ <br />J'checkil 537 | <br />that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />j C_ DATE: / C} <br />'c^o <br />Title <br />Address /a^ <br />Phone J — Phone <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 applicatinp/ar?ci <br />Standards, STATE and FEDERAL laws. .f j <br />APPLICANT’S SIGNATURE: ____________‘ <br />Assigned To . <br />r Email <br />□ Facility Contact <br />First Name <br />____\s.c<-vVU ________ <br />Address ~ <br />I a/T W HO SH-ro^-V, <br />Phone^c^ <br />Linked FA ID <br />Record Number <br />Payment 3 <br />Received By L/ <br />Facility Name <br />V'xs.'Vo __________ <br />Site Address .yj ~V^(-v-W'-SV <br />Supervisor District <br />V. \ C—Q Q LM V. <br />□ Application for <br />Operating Permit <br />Statec A <br />□ Other <br />*SgS8S^j»n. <br />Last name <br />rGj-J/ocf »— <br />□ Contractor