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K/Existing Facility New Facility <br />Facility Name <br />Site Address <br />LodiAPN <br /> Consultation Change of Owner Repairs or Remodel Other <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />S Billing Party Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />I Billing Party Ef Facility Contact Facility Owner Property Owner Contractor Architect <br />First Name If contractor, indicate type and license number <br />Phone <br /> Billing Party Facility Owner Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br />DATE: <br />13 OTHER AUTHORIZED AGENT OPERATOR/MANAGER <br />Linked FA IDAssigned ToAccepted By <br />1^02. <br /> Check # <br />Rev 07/10/2024 <br />lldll .Phone <br />Last name <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br /> Application for <br />Operating Permit <br />Date <br />i-is-as <br /> Cash <br />ZIP <br />H'Facility Owner <br />VI crA) <br />State <br />Type of Service <br />Requested <br />Comments <br />___221 <br />Email <br />First Namei <br />a-____ <br />Address <br />Phone <br />\JP_ <br />PE <br />San Joaquin County Environmental Health Department <br />Application Form <br />Gicuvt H dm _ <br />5 (p4-Q Re-undldS P___ , <br />Supervisor District <br />ZIP <br />35540 <br />Ayr. <br />Email <br /> Facility Contact <br />State cA <br />ZIP . <br />Last name <br />City <br />gv Ce^i~r^ <br />gf Confirmation If <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 and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ord yay e Codes, <br />Standards, STATE and FEDERAL lawsr^^cT) /2- <br />APPLICANT'S SIGNATURE: DATE: /'"/ ~ <br />gfpROPERTY / BUSINESS OWNER □ OPERATOR / MANAGER & OTHER AUTHORIZED AGENT <br />Tit/ 13 <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, the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRO^fi^l^ <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />F/W 35319 <br />Record Number <br />Apa50l4(g5Fec$l72 <br />FirsLName <br />■XyC/\________ <br />Addr/ss . <br />Phong. <br />• Sc