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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address r, _ �/� City �� State ZIP <br /> ' Q t� <br /> -3cz Hd d r CAL/ c� C—) Zd� C <br /> APN Supervisor District <br /> Type of Service A Application for ❑Consultation ❑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 ❑Facillty Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party wacllity Owner K,,Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> N PAR H <br /> Address as �� .J 0 5 GIYy� C �� State , 7y ZIP 9 'O <br /> Phone Phone Y" Email C�V� <br /> ❑Billing Party ❑Facility Owner L]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 ❑Faclllty Contact ❑Property Owner ❑Contractor C7 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 <br /> (all SAN JJO¢AQUIN COUNTY Ordiq®p� des, <br /> Standards,STATE and FEDERAL laws. J, 7/ � DATE: 75` ffl��_1 R•F/�` & r <br /> APPLICANT'S SIGNATURE �✓�J � n <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER Cl OTHER AUTHORIZED AGENT <br /> Title (J ri <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required -"4IV <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address h J. <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIROI "0UN <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative, �� NraC <br /> Accepted B Assigned T Linked FA ID <br /> Date �2,rX PE ��� R cv Numbx <br /> ❑Cash ❑Check R Confirmation st l(11J��2�� T�Payro`en <br /> ived By <br /> Rev 07/10/2024 <br /> P22S�o I I <br />