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, New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> FacilikvNam@ t / �� e ' 1 q <br /> Site Address S 1 ,y State Zl <br /> 3 0 C a j o r�n l V� o ,� S d ob <br /> All Supervisor District <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments � f <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party Facility Owner ❑Facility Contactr*1roperty Owner ❑Contractor ❑Architect <br /> First Name n 1 �{ ,n I U` 4 Last na F r u r{ If contractor,indicate type and license number <br /> Address 5 ' <br /> rt a ` r Vl I V4 I Oily r State ZIP <br /> o tjfu�1 ! 5 tokl C14 J aJ6 <br /> Phone/� Phone Email <br /> V 9lJ O 135 u r e G(s t! Gr r'�loon I — - <br /> ❑Billing Party ❑facility Owner acility Contact ❑Property Owner M Contractor ❑Architect <br /> First Name Last n e If contractor,indicate type and license number <br /> - <br /> Address City State ZIP 6 <br /> - 1 SEc(_r <br /> Phone Phone Email <br /> r Flo 98'- <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor t <br /> First Name Last name If contractor,indicatJt)V6kJE1Vrd <br /> r <br /> Address City State A JA 73 202 <br /> Phone Phone EmailHtOR UlAi CpUN <br /> l. <br /> TY <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that a I ject <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 arW that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws L <br /> PLICANT'S SIGNATURE: DATE: J <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,1,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 /> Accepted By Assigned Tom^ Linked FA ID <br /> Date Ill <br /> �2_ PE D Fee �� oU Re spr umr erD <br /> h rLl3 L7-`f/ qxo <br /> Payment <br /> ic <br /> s , VD ❑Check II ❑Confirmation If Received By <br /> Revo7/io/zoza �� �,5 �1-1 2 LPJI RC P (o Is ' <br /> P�2 OD0�� <br />