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Pq New Facility ❑ Existing f=acility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Fact Nam \ <br /> Sits @ddress 1^ '� Git Stte� 2fP <br /> APN Supe :sor 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 1crise Plate Number VIN <br /> pumper truck V CA1�n] <br /> Contact Types C7 Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> l� <br /> Biding Party ,R',jFacilityOwner Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name La name \1 If contractor,indicate type and license number <br /> Address ` �� Stat ZIPIrj�'�.0 <br /> Phone tPone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Agitect PA <br /> First Name Last name If contractor,indicate type al <br /> 1 <br /> Address City State <br /> C <br /> Phone Phone Email J <br /> /Iv <br /> cnr <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑ATcVI[ rA4jVr <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 HEA6aws. <br /> MENT hourly charges associated with this project or activitywill be billed to me or my business as Identified on this <br /> form, <br /> S also certify that I have preparaY n that th work to p rfo ed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards, <br /> ANSTATE <br /> SIG and FEDERAL �O>� n 4 <br /> APPLICANT''SIGNATURE: DATE: L <br /> ❑PROPERTY/BUSINESS OWNER fo�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 /> Accep edy Assi ned To Linked FA ID <br /> i/1dol P. IadecEnne <br /> Date PE Fee c d Number <br /> �mIZ�112`i 11�{�3 $1�z CLIA 2'-4 V MO, . <br /> Rev 06/12/2024 r � � �7.2• 6 6 `�"� �����r� ��� � - <br />