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San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name�(-\ ` <br /> Site Address i(,0 5-1) Ot Wlob /Ta� 1 C/•VA1ity un'V,Cc'-, L Stater ZIP/{ r hJ s <br /> APN Supervisor District U` <br /> 3 <br /> Type of Service y'lCi\pplica*ion for ❑Consultation C 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 ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billirg Party .SrFacihty Owner .141 Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> AddressAu I�` 1 Cit Stat Z P� <br /> hone hone Email <br /> how-7L6-$ _ g q , ; say <br /> ❑Billing Party C Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license numbe <br /> Address City State Z'P <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 /> Phone Phone Finail <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owrer,operator or authorized agent of same,acknowledge that all site and/or project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated v,' 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 thi placation and th w rk t be performed will be done in accordarce ah all IN jOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL la• —7 0 <br /> APPLICANT'S SIGNATURE: DATE: <br /> S,PRODERTY/BUSINESS OWNER =OPERATOR/MANAGER ❑OTHER AUTHORIZEDAGENT <br /> Title <br /> If APPLICANT is not the BILLING PARTY,proo`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 a:the same time it is provided to me or my representative. <br /> 4 <br /> Accepted By To Assigned �1 <br /> J.. r <br /> Date PE Fee Ketwd Number <br /> 20�7 <br /> RAN/ co <br /> N� �� � l ` ( J N��A�FNT�NTY <br /> �RWIV), <br />