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; (Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address State <br />APN <br /> Other Repairs or Remodel Change of Owner <br />License Plate Number VIN <br /> Architect Contractor Billing Party Facility Owner Property Owner Facility Contact <br /> ArchitecttTi Billing Party ContractorU Facility Contact Property Owner <br />If contractor, indicate type and license number <br />Zll <br /> ArchitectQ Billing Party Contractor Facility Owner <br />If contractor, indicate type and license number <br />State <br />Phone <br /> Architect Contractor Property Owner Facility Contact Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />State ZIPCityAddress <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT !Title <br />I <br />Assigned ToAccepted By <br />F. <br />/WT I <br /> Cash <br />Rev 07/10/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <br />_________Application Form <br />__22-Cn Qonn+ru Cinto <br />Supervisor District ) <br />^^Consultation <br />'■^Facility Owner <br />Type of Service <br />Requested <br />Comments <br />First Name <br />\ I /_____ <br />TZtQ"! Coori-iv, <br />Phone <br />I $1^; <br />c'^-fcxXkr~] <br />First Name <br />Addre: <br />Last name <br />_ ______________l- ;<\v- <br />Phone" ~ J Phone Email I <br />zcA '-iuw <br />ress, hereby authorize tl^P^ 1 <br />____________ <br />Confirmation » <br />| Received By^ <br />tofrzwjww-aiaiocj, <br />State , C3A. <br />Last name . <br />V/Tj.fS ^-1 [a. <br />ciix ( <br />.Jry______ <br />[^facility Contact Property Owner <br />BILLING ACKNOWLEDGEMENT: I, the undersigfled 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 performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />oatci____/AV/cP/. PAYMFA t <br />^PROPERTY / BUSINESS 0WNER_ □ OPERATOR / MANAGER □ OTHER AUTHORIZED AGENT <br />' T'tlC CCD <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required ' t D Q 2 <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site addrgss, hereby authorize tl <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVII <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative_________________________ <br />“ja.qatol'TtoD'A <br /> Check «