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Existing Facility□ New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />APN <br />s/change of Owner □ Repairs or Remodel □ Other□ Consultation <br />License Plate Number VIN <br />□ Facility Contact□ Billing Party □ Facility Owner □ Property Owner □ Contractor □ Architect <br />^.Billing Party Facility Contact □ Architect□ Property Owner □ Contractor <br />If contractor, indicate type and license number <br />□ Architect□ Property Owner □ Contractor□ Facility Owner□ Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPStateCityAddress <br />EmailPhonePhone <br />□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party <br />Last nameFirst Name <br />StaiCityAddress <br />EmailPhonePhone <br />□ OTHER AUTHORIZED AGENT□ OPERATOR/MANAGER <br />Assigned ToAccepted By c? <br />Fee ct- <br />PRbS«nO44Rev 07/10/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />□ Application for <br />Operating Permit <br />[^PROPERTY / 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 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 />□ Confirmation t; <br />State <br />c A <br />S Si <br />Supervisor District <br />iUNTY Ordinance Codes, <br />Type of Service <br />Requested <br />Comments <br />Last name <br />Ao 11 _______ <br />Site Address . <br />SV <br />Email <br />reH I I , <br />□ Facility Contact <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. <br />I also certify that I have prepared this application and that the work to be perfop <br />Standards, STATE and FEDERAL laws. Z Z ' 7/APPLICANT’S SIGNATURE: V (Z- C f: <br />/^Facility Owner <br />□ Check » <br />: to be performer? will be done in accordance with all SAN JOAQUIN GOUN. . <br />S>) \T\ / DATE: <07 (c & ( <br />-e <br />Title <br />Zlp^ — <br />"I Payment <br />Received By <br />^ef®® ense number <br />Firef»Name <br />Pnone'" Phone <br />IQ ____________ <br />State <br />CA <br />□ ContractorJUL „ u <br />If corSj^j^x^jndicate type