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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> TG o- <br /> Site Address City State ZIP <br /> . 0 5. Cal 0f'n 1 Cp CIS WS <br /> APN Supervisor District <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 Numberr f VIN <br /> pumpertruck of &G'h� �SwvwS1 5650�15bgC <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party ff Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> t Name Last name If contractor,indicate type and license number <br /> FirV10b o yC\ <br /> Address ` Ci C <br /> StatA_ C15�� <br /> ZIP <br /> 2C1 5 to cma c 1, <br /> p'jone,L O r Phone Email ly� <br /> ❑l 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 7-Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor 7-6 <br /> Architect <br /> First Name Last name If contractor,indicate type and linumber <br /> Address City State ZI C/' ie <br /> ® � <br /> Phone Phone Email 2020 <br /> 24 <br /> Aq <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge t t "E BTM <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as i <br /> form. NT <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. f1/ILJ <br /> APPLICANT'S SIGNATURE: U DATE: (7 h L <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 /> uefp <br /> Date PE Fee Record Number <br /> l0 ubtsq 4162.0 PPNW S 33 <br /> F6Q- I(,2 bd IS 3Lf1 <br /> pRI� ODzI I <br />