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f<X\t <br />Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Site Address City ZIP 952 HoLODI <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />Facility Owner Billing Party Contractor Architect Facility Contact Property Owner <br />If contractor, indicate type and license numberFirst Name Last name <br />State ZIPAddress H52HOCA <br /> Contractor Architect Billing Party Facility Owner <br />If contractor, indicate type and license numberLast nameFirst Name <br />State ZIPCityAddress <br />EmailPhonePhone <br /> Contractor Architect Property Owner Facility Contact Billing Party Facility Owner <br />If contractor, indicate type and license numberFirst Name Last name <br />ZIPStateCityAddress <br />EmailPhonePhone <br />m and tha/tllis ai worl <br />DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER <br />Title <br />> <br /> Check it Cash <br />Rev 07/10/2024 <br />flS Itlc’iid.CsW <br />I J — <br /> Property Owner <br />lared <br />iALIa <br />[Confirmation # <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 />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 haveprc <br />Standards, STATE and FED? <br />APPLICANT'S SIGNATURE: <br />Type of Service <br />Requested <br />Comments <br />ROblvf <br />ft Sc hooFy City <br />DOfthOUX MkE-Py <br />*8 (V- SCHOOL- ST ft <br />Supervisor District <br />:b be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Assigned To <br />Fee $n2.(zxz)Date <br />Q>W&\2Q)2S <br />State <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required '^3 1^ <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, h&tyy author*/^c <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONM^H <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />------------------------------------------ <br />_ <br />Accepted By <br />C- <br />PE . <br />Linked FA ID <br />Record Number <br />-tw <br />________ <br />Email . . <br /> Facility Contact