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[�I New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form iQ25cxD?;Dq <br /> Facility Name i `� �iA •/I^� I�j�� <br /> Site Address �2 O vl � � ��i L� City S, J StateC4 ZIP <br /> APN 7 Supervisor District <br /> Type of Service Application for Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Pl1a�te Number VIN Jpumper <br /> truck _1 W l(?3 Z <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 ❑Architect <br /> First Name I^� Last namt A,2 C,-;-\ Vn I �—P If contractor,indicate type and license number <br /> Address q ' n� � i tQ n� City State ^� ZIP„ <br /> Phone 4/ Phone �/1 l 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 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 Email <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 Ordinance Codes, <br /> Standards,STATE and FEDERAL I { <br /> APPLICANT'S SIGNATURE:X -r¢i� hI DATE: I� ;`2- d♦,&, <br /> ❑PROPERTY/BUSINESS OWNER OPERATOR/MANAGER El OTHER AUTHORIZED AGENT � p�J <br /> Title JA, <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 addrAiM9"0Pa"% <br /> . authorize tl <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRON DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. �(T NM UN <br /> Accepted By r V Assigned To I Linked FA ID NT <br /> Date V Record Number <br /> -� -ZV� PE Fee /�P250 L147 <br /> Payment <br /> Cash ❑Check H ❑Confirmation# Received By <br /> Rev 07/10/2024 <br />