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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Supervisor District <br /> Consultation Change of Owner Repairs or Remodel Other <br />Lic^nie Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br /> Facility Contact Property Owner Contractor Architect Billing Party Facility Owner <br />If contractor, indicate type and license number <br /> Contractor Facility Contact Property Owner Architect Facility Owner <br />If contractor, indicate type and license numberLast nameFirst Name <br />State ZIPCityAddress <br />EmailPhonePhone <br /> Property Owner Contractor Architect Facility Contact Facility Owner Billing Party <br />TnberLast nameFirst Name <br />StateCityAddress <br />EmailPhonePhone <br />Title <br />Linked FA ID <br />R~ <br /> Check tt Cash <br />Rev 07/10/2024 <br />^25009^5 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <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 COUNI Y ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />ZIP <br />\ <br />Type of Service <br />Requested <br />Comments <br />^Confirmation 7(3^? <br />Record Number <br />Payment <br />Received By <br />If contractor, indicate type and £4 <br />Facility Name , , u <br />Site Address x <br />APN <br />stcL A <br />First Name , <br />Address . . <br />BhoneI Phone <br /> Billing Party <br />PE <br />Accepted By <br />JeVT C. <br />Date .KZ)la>5l2.S <br />state(L^ <br />Assigned To <br />Fr one \ sce> <br />Fee <br />0© <br />0c/- D <br />_______________________________________ - <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowl project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my <br />form <br />I also certify that I have prepared this^gplication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY OrdinJT'c^.fes, <br /> -An: _ <br /> PROPERTY / BUSINESS OWNER OPERATOR / MANAGER OTHER AUTHORIZED AGENT .