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facility Name <br />(I <br />APN <br />O Consultation change of Owner <br /> Other <br />or License Plate Number <br />VIN <br /> Billing Party Facility Owner Facility Contact Property Owner <br /> Architect <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />First Name <br />Last name <br />If contractor, indicate type and license number <br />Address <br />ZIP <br />Email <br /> Billing Party Facility Owner 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 Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />EmailPhonePhone <br />DATE: <br />OTHER AUTHORIZED AGENT <br />Linked FA IDAssigned ToAccepted By <br />FeePE <br />Contact Types <br />required <br />Type of Service <br />Requested <br />Comments <br />Title <br />If mobile food truck <br />pumper truck <br />Phone <br />7602 |F“ l^\ ~ <br />& <br /> Facility Contact <br />Phone <br />z,p^ - <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 />I also certify that I have prepared tHraplication 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./ i / 7 ->/)-> ,---- <br />APPLICANT'S SIGNATURE: -------------------- DATE: —---------------------- <br /> PROPERTY / BUSINESS OWNER OPERATOR / MANAGER <br />A <br />T Contractor <br />sante’u'nCoZ7r ~ application Form <br />Record Number <br />Sp. 2.SQ <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 />=e ofZ andXsu^ geotechnical data and/or environmental/slte assessment Information to the SAN JOAQUIN COUNTY ENVmONMENTAL health <br />DEPARTMENT as soon as It is available and at the same time it is provided to me or my representative.--------------------------------------------------------------------------------------- <br />Site Address <br />Supervisor Distrty <br />^AUpllcation for “ <br /> Operating Permit <br />State . <br /> Repairs or Remodel