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� M V <br /> San Joaquin County Environmental Health Department <br /> Application Form AP B ODVG f <br /> FAP <br /> ty Name <br /> ---siteddr�, w w �Q City State n^ ZIP <br /> Supervisor District <br /> Type of Service FrApplication for ❑Consultation O 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 O 811111ing Party ❑FacgRy Owner ❑FadkyCo Es 0 Property qComractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name f contractor,indicate type and license number <br /> Last name I <br /> chi, /vd o9112Y <br /> Address� r�A ll I �� City�lk State ^A ZIP p1 <br /> Phone- � <br /> 1vl Phone mail <br /> 2� <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor 70`A—rc1,1e,1 <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone E ail <br /> ❑Billing Party ❑Fa ty Ow r Fa ity Contact ❑Property Owner ❑Contractor ❑Architect A Y <br /> First Name L st name If contractor,indicate type and license nr FNr <br /> Address City State ZIP <br /> ���FO <br /> Phone Pho a Email ' QU�024 <br /> 11y <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or pr ]M <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 T <br /> form. <br /> ! I also certify that I have prepared this application' th Lthe work to be performed will be done in accordance with all SAN JO'AQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws`^-- - (/^-- <br /> APPUCANrS SIGNATURE: DATE: <br /> ❑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,geolechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY E%11 M11E >L HE L <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. —�1( {1��a��_ <br /> Accepted By Assigned To /� ` �— Linked F <br /> Date ` �; PE �. Fee Re WN b <br />