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New Facility <br />San Joaquin County Environmental Health Department <br />APN <br />JZfchange of Owner Consultation Repairs or Remodel Other <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />Si Billing Party ^Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />Phone Email <br /> Facility Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last 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 />EmailPhonePhone <br />DATE: <br /> PROPERTY / BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br />Title <br />Assigned ToAccepted By <br />FeeDate <br /> Cash <br />Rev 07/10/2024 <br />Contact Types <br />required <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 provided to me or my representative. <br />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <br />Payment <br />Received By< <br />State <br />Confirmation # <br />Type of Service <br />Requested <br />Comments <br />Existing Facility <br />izv u-v e <br /> Check II <br />RKOrdNumb 8^^40015! <br />Application Form <br />Fac,',tyNa^^5Z^-s- <br />Site Address x—) /S s/ <br />I Supervisor District <br />ZIP <br />95^ <br /> Architect <br />If contractor, indicate type and license number <br />First flame <br />rac/'7<z£f <br />State <br />C.4- <br />Xa.c,/CoS AcdSt Com <br /> Facility Contact Property Owner <br />La^Lname <br />_______________ _______________ <br />PiO/i eer _______/fyco? /-eco <br /> Billing Party <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site d'hd/G project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified oft 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 FEDERALlaws. £2 ) <s) "2 ) LJAPPLICANT'S SIGNATURE: DATE: / 7