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□ New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Site Address <br />APN <br />5<Change of Owner □ Repairs or Remodel □ Other□ Consultation <br />VIN <br />■^killing Party □ Property Owner □ Contractor □ Architect <br />□ Contractor □ Architect□ Facility Contact □ Property Owner□ Billing Party □ Facility Owner <br />If contractor, indicate type and license numberLast nameFirst Name A <br />StateAddress A2- <br />Phone <br />□ Architect□ Property Owner □ Contractor□ Facility Owner□ Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPCityStateAddress <br />EmailPhonePhone <br />□ Contractor □ Architect□ Property Owner□ Facility Owner □ Facility Contact□ Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPStateCityAddress <br />Phone EmailPhone <br />DATE: <br />□ OTHER AUTHORIZED AGENT □ PROPERTY / BUSINESS OWNER <br />Title <br />Assigned ToAccepted By <br />RecordFeeDate <br />o <br />Confirmation #□ Check H□ Cash <br />Rev 07/10/2024 <br />Contact Types <br />required <br />□ Application for <br />Operating Permit <br />U[ <br />specific ENVIRONMENTAL HEALTH DEPARTI <br />form. <br />I also certify that I have prepared this applic <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <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 />Phone <br />ZIPState <br />c-A <br />^^Facility Owner '^^acility Contact <br />Email <br />□ Facility Contact <br />■g-f K J.NCL-_______ <br />City <br />Existing Facility <br />4^ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authc _d agent of same, acknowledge that all site and/or project <br />dENT hourly charges associated with this project o- .ivity will be billed to me or my business as identified on this <br />ftion and that the work to be performed will oe ne in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />____ DATE: . <br />^OPERATOR / MANAGER <br />Zlp86 <br />Supervisor District <br />Received By <br />.0 f 1 <br />PE 1^0^ <br />Ud ■ Rb P Hee mi*. <br />'W>\ ‘ ^-€T\AA, <br />Type of Service <br />Requested <br />commmts <br />If mobile food truck or License Plate Number <br />pumper truck