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Existing Facility□ New Facility <br />Fadlrty Name 1 CJc-k T <br />Site Address <br />APN <br />wthange of Owner □ Repairs or Remodel□ Consultation □ Other <br />license Plate Number VIN <br />□ Property Owner □ Architect□ Fadlrty Owner □ Facility Contact □ Contractor□ Billing Party <br />□ Architect|2J Billing Party £3-Fadlrty Contact □ Property Owner □ Contractor0Tadlity Owner <br />If contractor, indicate type and license numberLast name <br />ZIP <br />^52-^7 <br />Phone <br />□ Contractor □ Architect□ Property Owner□ Fadlrty Owner □ Fadlrty Contact□ Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPCityStateAddress <br />EmailPhonePhone <br />□ Property Owner □ Contractor □ Architect□ Facility Owner □ FadBty Contact□ Billing Party <br />Last nameFirst Name <br />City StateAddress <br />EmailPhonePhone <br />I DATE: <br />BtjPERATOR / MANAGER □ OTHER AimiORIZED AGENT □ PROPERTY / BUSINESS OWNER <br />Assigned ToAccepted By <br />PE <br />□ Check# <br />I also certify that I have prepared this aj <br />Standards, STATE and FEDERAL laws. <br />APPLICANTS SIGNATURE: __________ <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RFI FAST 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 ail results, geotechnical data aruVor environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is availabie 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 />San Joaquin County Environmental Health Department <br />Application Form <br />Contact Types <br />required <br />Scanned with <br />IS CamScanner <br />□ Cash <br />Type of Service <br />Requested <br />Comments <br />"-'So <br />^026 <br />t-lSol NJ <br />Supervisor District <br />State <br />C4^ <br />Email <br />mg <br />RKO.dNu.nbe. <br />Payment T// <br />Received By <br />A-1 /Vz^Iai?v> <br />Phone 0 <br />BILLING ACKNOWLEDGEMENT: L the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site anc <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as Hentii <br />■at the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Co&V^ y. <br />If contractor, indicate type and license nur^fc^r <br />/ <br />S)VT?rk_______ <br />City <br />City <br />Mwyiez- <br />Title <br />Z|pState <br />First Name <br />Address