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New Facility □ Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address City ..5 <br />APN <br />z0'Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />IU6 <br />VIN <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />□ Billing Party □ Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license number <br />□ Billing Party □ Facility Owner □ Facility Contact □ Contractor □ Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />EmailPhonePhone <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 />Phone EmailPhone <br />DATE: <br />□ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGER□ PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA ID <br />PE <br />I GO 3 <br />□ Confirmation it□ Check # <br />R?2SOO3l0Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />□ Application for <br />Operating Permit <br />Payment <br />Received By <br />State ZIP <br />■"tTFacility Owner <br />Type of Service <br />Requested <br />Comments <br />License Plate Number <br />PtAlT- <br />Jj , Record Number <br />Email <br />State <br />Assigned To <br />Fee______n 2.q I <br />vx/ <br />itbeccerz^ <br />□ Property Owner <br />ZIP <br />First Name Last name <br />Address" j / , U <br />___________Application Form <br />f Am Ter C-Qo <br />310^ <br />Supervisor District <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. <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 />Standards, STATE and FEQEaAQaws. \l\ r / Q ) t------ <br />APPLICANT'S SIGNATURE:DATE: (J) f / ^ \ / ) <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required '^Sypiry <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address hereby authoFlMhe <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL,! H <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.S/Vy j J