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San Joaquin County Environmental Health Department <br /> Application Form <br /> `V'�601A SeeP .Scar a <br /> Sit Address St to ZIP <br /> Ao a DC <br /> APN Supervisor District <br /> Type of Service plication 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 /> pumper truck <br /> Contact Types _Aping Party Vacility Owner U racility Contact (,..roperty Owner ❑Con ractor ❑Ar itect <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact 7 <br /> Property Owner ❑Contractor ❑Architect <br /> Fi Name Las n e If contractor,indicate type and license number <br /> rl to <br /> A4 lwsv <br /> CA State ZIP <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 Party ❑Facility Owner ❑Facility Contact 7 <br /> Property Owner ❑Contractor <br /> First Name Last name If contractor,indicate type a s n b2024 <br /> Address City State OAQUIN COUNTY <br /> ENVIRONMENTAL <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 RTMENT 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 is ap ' do and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL la s. 11 I azt— <br /> APPLICANT'S SIGNATURE: DATE: <br /> %P'RROPERTY/BUSINESS OWNER 4ePERATOR/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 /; i Linked FA ID <br /> Date PE Fee Record Number <br /> 1 <br />