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New Facility Existing Facility <br />Application Form <br />ZIP7^ <br /> Consultation Change of Owner Repairs or Remodel Other <br />VIN <br /> Facility Contact Property Owner Contractor Architect <br /> Property Owner Contractor Architect <br />If contractor, indicate type and license numberLast name <br />lA ^^6 <br />Phone <br /> Facility Owner Facility Contact Property Owner Contractor Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address City State ZIP <br />Phone Phone Email <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor <br />First Name Last name <br />Address City State <br />Phone Phone Email <br /> OTHER AUTHORIZED AGENT <br />Title <br />Assigned Tj Linked FA ID <br />PE FeeDatelb03 <br /> Check U <br />Rev 07/10/2024 <br />San Joaquin County Environmental Health Department <br />If mobile food truck or <br />pumper truck <br />State <br />^/confirmation # <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 provide^ tp ma,or my lytyesgntative. <br />Type of Service <br />Requested <br />Comments <br />^Facility Owner <br />L~D-Application for <br />Operating Permit <br /> Billing PartyContact Types <br />required <br />p Billing Party <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 FEDERALJaws. 4 . // -/ i / <^) 'I <br />APPLICANT'S SIGNATURE: G / V j DATE: ryC / Z^Z <br /> PROPERTY / BUSINESS OWNER OPERATOR / MANAGER <br />ded tp ma < <br />State <br />GA <br />Facility Name <br />Cm C(\ <7 <br />Site Address . v <br />APN Supervisor District <br />.Email <br />AcceptedB<\/^A <br />Date / / <br /> Cash <br />/ XWg <br />Address <br />\ /?o$ A?/ <br /> Billing Party <br /> ArcnTtAu/^^.^ <br />If contractor, indicata^je andlhcrfis£ <br /> Facility Owner <br />^Facility Contact