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53^^ <br /> New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br /> Consultation Change of Owner Repairs or Remodel Other <br />VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />-ja^Facility OwnerBilling Party Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />State <br />Phone <br /> Facility Owner Facility Contact Property Owner Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address City State ZIP <br />Phone Phone Email <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor <br />First Name Last name <br />btC 0|9lp20-jAddressCityState <br />EmailPhonePhone <br /> OTHER AUTHORIZED AGENT PERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAssigned To <br />Fee <br /> Confirmation It:heck It <br />1Rev 07/10/2024 <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 />Contact Types <br />required <br />Payment <br />Received By <br />I also certify that I have prepared thirSppH <br />Standards, STATE and FEDERAL laws.S^K <br />APPLICANT'S SIGNATURE: _______// <br />^^Facility Contact <br />Type of Service <br />Requested <br />Comments <br />^^30^ <br />Site Address <br />7^30 APN <br />PAYWIET''te'cr <br />If contractor, iniicd& <br />Date <br />fcj/^ish <br />:ense riumber <br />First Name <br />" idress , _. <br />State a <br /> Facility Contact 1 Property Owner Contractor p a„u;» <br />AcrepledTXT<v<lSco <br />PE <br />Last name ^-7 <br />PAaym ve. <br />13 Hv ~T t\ VX - <br /> Billing Party <br />Z - Facility Name ■ <br />Site Address ' ’ \— Cjauwi ru pC_____c. <br />Supervisor District <br />SA.j JOAQUIN <br />E-1'^ IROnImeNTAI <br />_____________ ______ — DEPARTMENT <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. __x. t I <br />performed will be done^A^cordance vMi^a^AN JOAQ^N COUNTY Ordinance Codes, <br /> OPERATOR/MANAGER <br /> Application for <br />Operating Permit <br />If mobile food truck or License Plate Number <br />pumper truck