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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> ed <br /> Site Address l`tC� R Cit 11 11 State ZIP <br /> �C� -5 Z t-G �rO4.LQ J�CL_! tv" C iL CU C <br /> APN Supervisor District <br /> ND•30o-Oou <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel Q Other <br /> Requested Operating Permit <br /> Comments <br /> ftl i-r:n rJ-cc 4c p <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact 0,Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,Indicate type and license number <br /> 1nti� <br /> Addre s city State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner FLContractor ❑Architect <br /> First Name Last name If contractor,Indicate type and license number <br /> /1 - /ot2 y <br /> Address city State ZIP <br /> T.D. cA `rS4(o <br /> Phone Phone Email <br /> 53c7--5$4-zolc <br /> Ed Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> 0, vlrck <br /> First Name Last name If contractor,indicate type and license number <br /> r u Ct-�t <br /> Address City State ZIP <br /> I�ZA P Acs wa K:�c 4 \�k ' ,Ur- �L 95�7v <br /> Phone Phone Email <br /> ` 1f0• `//& 11?- £f <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 performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> � I ` <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ?Q OTHER AUTHORIZED AGENT Lh t f— PrtSLr�.I�- <br /> Title <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign Is required <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,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 /> Accepted By Assigned To `j Linked FA ID <br /> Date fo <br /> Fee Record Number <br /> ���j �3 Ra 8a <br /> ❑Cash Check K kkonfirmation N Payment <br /> Received By <br /> Rev 07/10/2024 <br />