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□ New Facility □ Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />CA <br />□Knange of Owner□ Consultation □ Repairs or Remodel □ Other <br />lumber VIN <br />□ Billing Party □ Contractor□ Facility Owner □ Facility Contact □ Property Owner □ Architect <br />[STBilling Party □ Contractor □ Architect□ Facility Owner □ Facility Contact □ Property Owner <br />If contractor, indicate type and license numberLast name <br />State ZIP <br />2^ 12-C A <br />Phone <br />□ Property Owner □ Contractor □ Architect□ Billing Party □ Facility Owner □ Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />EmailPhonePhone <br />□ Contractor □ Architect□ Facility Contact □ Property Owner□ Billing Party □ Facility Owner <br />If contractor, indicate type and license numberFirst Name Last name <br />State ZIPCityAddress <br />Phone EmailPhone <br />. DATE: <br />□ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGER□ PROPERTY / BUSINESS OWNER JAN 1 3 202(Title <br />Assigned To <br />I <br />□ Check tt□ Cash <br />Rev 07/10/2024 <br />RS 06^101SM <br />Contact Types <br />required <br />Payment <br />Received By <br />□ Application for <br />Operating Permit <br />Email <br />City <br />5 <br />Datei-n-u <br />State <br />< <br />Type of Service <br />Requested <br />Comments <br />( First Name <br />I Address <br />I Phone , s _ <br />If mobile food truck or License Plat <br />pumper truck <br />Supervisor District <br />City <br />S'T’o C ' O <br />Accepted By <br />C L<r <br />PE <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 addre&A^reiP AfiWoWH SPU 4 IT <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONNfEWMlRjOWMErJ IA _ <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.HEALTH DEPARTMENT <br />Record Number <br />'Confirmation tf ^Wi^s^ <br />ZIP <br />k? (Z- <br />FeeSnq^ <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. r <br />l&Lsq certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY^^'^i^^^rte?',., <br />■Starfaards, STATE and FEDERAL laws..—j \ . i z-. „/ _, — —■>"< i-*.APPLICANT'S SIGNATURE: ^7 1 _________________X DATE. I I RECEIVE 3 <br />( Facility Name <br />Site Address <br />I---- APN