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Existing Facility <br />Site Address <br />Stale ZIP <br />APN <br />n Change of Owner ft Repairs w Remodel <br />3 ZPr>Jr\ <br />VBfFaciiity Owner Property Owner Facility Contact Contractor Architect <br />E^tlilling Party Li facility Contact Property Owner Contractor Architect <br />First Name <br />If contractor, indicate type and license number <br />Address State <br /> Billing Party Facility Contact Architect Property Owner <br />First Name Last name If contractor, indicate type and license number <br />-'V <br />Address City State ZIP <br />Phone Phone Email <br /> Property Owner Facility Owner Billing Party <br />Last nameFirst Name <br />CityAddress <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT <br />Linked FA IDAssigned To <br />Fee/P3Date <br /> Check # Cash <br />Rev 07/10/2024 <br />Payment <br />Received By <br />Accepted By <br />——1 ' 1 PE <br />ptrnx'V <br /> Other <br />_________ <br />Supervisor Dis *'0 <br />^Supplication for <br />Operating Permit <br />Facility Contact <br />VIN <br />'mlik <br />T<i5 Billing Party <br /> gSS <br />Q^acility Owner <br />Facility Owner <br />J <br />.perator of the property located at the above site address, hereby authorize the <br />mt information to the SAN JOAQUIN COUNTS ENVIRONMENTAL HEALTH <br />my representative. _ <br />SI <br />Contact Types <br />required <br />i i^U-OOi CH- <br />•|2J\ 7 th <br />Requested <br />Comments <br /> Contractor <br />US,IW.^ <br />Facility Name <br />Q New Facility <br />San Joaquin County Environmental Health Department <br />Application^orm <br />^ROPERTY/ BUSINESS OWNER <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 o| <br />release of any and all results, geotechnical data and/or environmental/site assessme. <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or <br /> ^f] Confirmation ff 0^ 3 <br /> Contractor _____ <br />If contractor, iGiftMetjpe and li^n^number <br />___________Stated Jq 1^0 <br />— <br /> <br />BILUNG 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 />I also’certify that I have prepared this applic^on and that thework to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />xJ^TX”laws- —— <br /> tZOPERATOR / MANAGER □ OTHER AUTHORIZED AGENT --------O ---------- <br />'C' Title <br />pT" <br /> Consultation <br />T7--i----—I- ° C- ll I ft I 1f mobile food truck or7 license Plate Number <br />pumper truck