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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Site Address State <br />APN <br />^5^Change of Owner Consultation Repairs or Remodel Other <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />’^.Billing Party ^Facility Owner Facility Contact Property Owner Contractor( Architect <br />If contractor, indicate type and license number <br /> Billing Party Property Owner Contractor Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address City State ZIP <br />Phone Phone Email <br /> Property Owner Contractor Architect Billing Party Facility Owner Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br />DATE: ^2 <br /> OTHER AUTHORIZED AGENT <br />Title <br />PE FeeDate <br />Migl Check « <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br /> Application for <br />Operating Permit <br />Type of Service <br />Requested <br />Comments <br />$ mr <br /> Confirmation It <br />Last name <br />L K MfAif <br />Supervisor District <br />First Name , <br />Address . <br />Phone| " 7Phone; <br />authorized!*' <br />Phone| Phone/ <br /> Facility Owner <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 addjg^/l <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />Accepted^Ya> <br />btes <br />cash war <br />(finance Codes, <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 application apd that the work toJ^e performed will be done in accordance with all SAN JOAQUIN COUNTY <br />Standards, STATE and FEDERAJJaws^/ <br />APPLICANT'S SIGNATURE: ' — <br /> PROPERTY / BUSINESS OWNER OPERATOR / MANAGER <br />Assigned To/ . ' <br />(72- <br />Linked FA ID <br />Record Number <br />f SR25C)iiee> <br />Payment <br />Received By <br />City <br />Email . <br />t <•»->_______ <br /> Facility Contact <br />State <br />cA <br />Cii