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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />ZIPSite Address City <br />APN <br /> Change of Owner Repairs or Remodel Other Consultation <br /> Property Owner Contractor Architect Billing Party Facility Owner Facility Contact <br /> Property Owner Contractor Architect Billing Party Facility Owner Facility Contact <br />If contractor, indicate type and license numberFirst Name last name <br />ZIPAddressCity <br /> Architect Contractor Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPCity-State 2AAddress 3 STS 7 4 <br />EmailPhone <br /> Architect Contractor Property Owner Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPStateCityAddress <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA ID <br />Record Number <br /> Check# Cash <br />Rev 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 <br />PE <br />E'Confirmation it <br />Type of Service <br />Requested <br />Comments <br />Email <br /> Facility Contact Property Owner <br />\ CpYV\ <br />Phone <br />trnan r~\ . —j „ <br /> Facility Contact <br />s,aZA <br />\Aa\<A <br />Supervisor District <br />License Plate Number A <br />I ,W> \ ■ Cpw\ <br />Assigned To <br />Lych'&- <br />Fee, <br /><2>Q> <br />Accepted By <br />/ cA/ P <br />Address \ <br />Phone z Phone <br />gAo-STt-feyZ- <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 thaj-fhe work to be performed will be done in accordance with all SAN JOAQUIN COUNT)' Ordinance Codes, <br />Standards, STATE and FEDERAL laws. 7/2/ / (A / / / / <br />APPLICANT'S SIGNATURE:DATE: ' I <br /> OPERATOR/MANAGER <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 ‘ft0 DfiOC <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HtAtTIr A J/.U <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.SAN JOAQUIN COUNTY <br />ENV1RONM EN tAL <br />HEALTH DEPARTMENT <br />Received By <br />State z .