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New Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address ZIP <br />APN <br />Gd Change of Owner Consultation Repairs or Remodel Other <br />VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />£9 Facility OwnerHsBilling Party Facility Contact Property Owner Contractor Architect <br />First Name Last name If contractor, indicate type and license number <br />Address State ZIP <br />'^^0 <br /> Facility Owner Facility Contact 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 <br />First Name Last name <br />Address City State <br />Phone Phone Email <br />Title <br />Accepted By <br />PE IbOZ, <br /> Check # <br />Rev 07/10/2024 <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 />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br /> Confirmation tl <br />Type of Service <br />Requested <br />Comments <br />/ nC <br />Cityru^. <br />__________Application Form <br />0<M~ <br />S5~ _______ <br />Supervisor District <br />S^xisting Facility <br /> Application for <br />Operating Permit <br />:k or License Plate Number <br />? ibtAMl^iH^d/or project <br />jsiness as iaem/VjcI on this <br />State^^ <br />I *7 5(^0 <br /> Property Owner <br />^0^9^14 <br />' z J _phone ___ _ Email <br />Assigned To / ’ / <br />T m <br />Phone rnune_ . ____ <br /> Billing Party <br />Linked FA ID_ x t <br />Record Number - <br />Payment , <br />Received By <br />Date I • <br />Encash <br /> Architect <br />If contractor, indicaArfc^rdTiEftfts^Vifnbcr <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge* <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business <br />form. <br />I also certify that I have prepared this apolicatioR and/hat the wprk to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> <br /> PROPERTY / BUSINESS OWGTER OPERATOR / MANAGER OTHER AUTHORIZED AGENT <br />ZIP