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San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name `& <br /> Site Address V u� � 1 ' "' C._ Stat - ZIP <br /> 2A\I APN Supervisor District 't��- <br /> Type of Service TApplication for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested dperating Permit <br /> Comments <br /> if mobile food truck or License Plate Nu b�( Vl�k I ) 4 9�7 <br /> pumper <br /> 0^r truck %J `` G 4'[1 4 <br /> Contact Types ❑Billing Party ❑Facillty Owner ❑Faclllty Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First NkmeCt La ale If contractor,indicate type and license number <br /> MWW <br /> Addres City State ZIP <br /> P one Phone Email <br /> -T <br /> ❑Billing Party 0 Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City Sta to ZI P <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <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 pre ared this application and that the work to be performed will be done in accordan�w th a`II AN 4OAgUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FED RAL I vl <br /> APPLICANT'S SIGNATURE: DATE: I^� <br /> PROPERTY/BUSINESS OWNER ❑OPERATOR/M AGER I7 OTHER AUTHORIZED AGENT <br /> iii Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required ^i <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,herea orize thel / <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONME TA� 0�7 <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. �� YRO yN C <br /> Fp v NlY <br /> Accepted By A�ed To Linked FA ID T <br /> rr <br /> �f <br /> bate PE 1 tee ! 'U !/ t'J'`•� L7�2. e� <br /> S <br />