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San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> rc Conl�Z <br /> Site Address City State ZIP <br /> 02 nd eef' a 1, 9537C0 <br /> APN Supervisor District <br /> S <br /> Type of Service Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumpertruck <br /> Contact Types It Billing Party pJ Facility Owner x Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party Facility Owner )l Facility Contact 7 <br /> ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> eA ro- ool 8- <br /> Address City State ZIP <br /> 3 <br /> z 62• a"Ol Sfr�ef" rGI ow 95737co <br /> Phone Phone Email <br /> z��t�-a-9�/ tafh�ra a�,tZ 1? mil . o <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 Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor EIVft <br /> First Name Last name If contractor,indicMJpe6rj H262yumber <br /> Address City State "I uVAU ENVIR NMEN�gNTM <br /> Fi <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 prepared this ap I' at' n and th the work to be performed will be done in accordance with all SAN JJOAQUIN(CCOUNTY Ordinance Codes, <br /> StanAPPLICANT'S S GNATU ards,STATE and ED\, law . DATE:/ <br /> PROPERTY/BUSINESS OWNER ❑OP TOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <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 /> Accepted By Assigned To D�q Linked FA ID <br /> Dat� PE (�� � Fee � (/ G"/ � Record Number <br />