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San Joaquin County Environmental Health Department r,c000ijo <br /> Application Form <br /> Facility Name <br /> ,l <br /> Site Address City State ZIP <br /> S � Zv l• n <br /> APN Supervisor District <br /> Type of Service ❑Application for WuPt Wo KrChange of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN _ <br /> pumpertruck t ® 9ZZ. X/tq Lj lj� <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑.Architect <br /> required <br /> Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor -T❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> V/C oY ,u z act m, )-r2 <br /> Address City State ZIP <br /> P one Phone ` Email <br /> ❑Billing Party Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor77� ❑Architect <br /> First Name Last name <br /> o /rl, .•Syr j •t?r i C <br /> Address City J State ZIP <br /> Phone Phone Email <br /> 9--2 y t'l- <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type an P"ANENT <br /> Address City State ZI P <br /> Phone Phone Email <br /> or-T" ID <br /> ENVI <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge tha UTWr41'�PApR* NT <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 and that the work to be performed will be done in accordance with all AN 72- <br /> IN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws/// T 4 <br /> APPLICANT'S SIGNATURE: - //L� �GCI'�`�+/ d"r-z— DATE: 1 �� <br /> LDS 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 /> GL 1�0.h Yl K, , L <br /> Date PE Fee Record Number <br /> 5 a4 � � � r s�a400145 <br />