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□ New Facility □ Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />2.6 632- O <br />State <br />C/A'Dr- <br />□ Other□ Consultation □ Repairs or Remodel <br />VIN <br />□ Architect□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor <br />!□ Contractor □ ArchitectBilling Party □ Property Owner□ Facility Owner □ Facility Contact <br />If contractor, indicate type and license numberFirst Name <br />State <br />Email <br />□ Architect□ Contractor□ Facility Contact □ Property Owner□ Billing Party □ Facility Owner <br />If contractor, indicate type and license numberFirst Name Last name <br />ZIPCityStateAddress <br />EmailPhonePhone <br />□ Architect□ Contractor□ Facility Contact □ Property Owner□ Facility Owner□ Billing Party <br />Last nameFirst Name <br />StateCityAddress <br />EmailPhonePhone <br />ition <br />Property / business owner □ OPERATOR/MANAGER <br />Linked PAIDAssigned To <br />PEDate,1(^02- <br />□ Cash □ Check W <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />Payment <br />Received By <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 />City ZIP <br />A <br />Type of Service <br />Requested <br />Comments <br />Title <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: - <br />□ Application for <br />Operating Permit <br />License Plate Number <br />^v1 <br />Phone Phone <br />^3 Change of Owner <br />Cl,,Sh)t^uvn <br />ra o o rr <br />^Confirmation « '2-'^] <br />Accepted By <br />Last name A <br />V\V\ <br />Supervisor District <br />If contractor, indicate type and license number <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledg^trt'C^^te and/oi^<5j?ct <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or on this <br />form. -Z______________________ _______________ ________ ... __________ <br />it the work to be performed will be done in accordance with all SAN JOAQUIN COUNTv.pjfiiffaH(e Codes, <br />rDATE: /- <br />7^ <br />□ OTHER AUTHORIZED AGENT <br />rr______/ Facility Name .7- rzgveP <br />Site Address <br />1 APN