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New facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form -pkaLA <br /> Facility Name \— o�; n C <br /> Site Address L.,.1 city State ZIP <br /> kZ 5 -1 1 Y �351 <br /> APN Supervisor District <br /> Type of Service ;;-Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments , ke z M r � (Amadov co W✓1kJ If mobile food truck or License Plate Number <br /> VIN �7 <br /> pumper truck <br /> Contact Types 0 Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party y Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> Fir ame L t name r If contractor,indicate type and license number <br /> W� <br /> r <br /> ddress qr� n City State <br /> ne Ph o a Email <br /> ❑Billing Party ❑Facility Owner ❑Fa cil-Y Cont ❑Property Owner ❑Contractor ❑Architect <br /> First N 'an <br /> a a If contractor,indicate type and license number <br /> Lc:)5 <br /> Address 5 ` Ci y State ,n ZIP <br /> Phone ` Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Ar <br /> First Name Last name If contractor,indicate type and lie num er <br /> Address City State ZIP <br /> QOUI 4TY <br /> Phone Phone Email jNV RQNMENTA <br /> EALTH DEPARTM INT <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 pr ared t is applicatio d that he work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and F ERA <br /> APPLICANT'SSIGNATU E: DATE: <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/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 Linked FA ID <br /> Date! ���`�. { PE ���� Fee Record 2y er q8 <br />