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❑ New Facility © Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name _ <br /> C Tacaw C I i <br /> Site Address City State ZIP <br /> 35S N C w^1d ►�� Loctj G AC) 5 2'1 O_ <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck q V>F( 70)15 yM°1 k4l E B 3 K S 0 5(3 b( <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner 0 Contractor ❑Architect <br /> required <br /> ❑Billing Party Q Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name V Last name If contractor,indicate type and license number <br /> D�n� <br /> Ad dress (��_ City State ZIP <br /> l Boa CR�brld� <br /> Phone Phone Email <br /> 510 -y�Sr�z ivc.,.�� , do18 <br /> ❑Billing Party ❑FacNty 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 ❑Contractor ❑Architect <br /> First Name Last name if contractor,indicate type and license number <br /> Address City State <br /> Phone Phone Lmail <br /> BILLING ACKNOWLEDGEMENT.I,the undersigned property or business owner,operator or authorized agent of same,acla edge that II it Ni project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed tome o Q4j/W as idenU d on this <br /> form. 11 1? Ay CO <br /> I also certify that I have prepared this applic on and th t the work to be performed will be done in accordance with all SAN76�'Y rRce Codes, <br /> Standards,STATE and FEDERAL laws. f f <br /> APPLICANT'S SIGNATURE: DATE: <br /> ❑PROPERTY BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <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 Et is available and at the same time it is provided to me or my representative. <br /> Accepted By Assigned To Linked FA ID <br /> Jec� C . F(C'A s C-,5 2 <br /> Date PE Fee Record Number <br /> M 4+ -z, I A 9 5 m 2q 15 <br /> Payment <br /> ❑Cash Q Check U tconfirmation p �{� (` Received By <br /> Rev 07/10/2024 ! D <br /> 1' 25i�-q-�`1 <br />