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New Facility ❑ Existing Facility <br /> f <br /> San Joaquin County Environmental Health Department <br /> Application Form P925C)01r2� <br /> Facility Name <br /> uvn 1 t6k l <br /> dress n / y state <br /> 1 <br /> APN Supervisor Distri <br /> Type of Service ❑Application for ❑Consuitation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or Lic nse Plate�lu�bAr VIN <br /> pumper truck i11J`('At `V I <br /> Contact Types ❑Hiking Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party gFacility Owner Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> irst ame Las name If contractor,indicate type and license nuMbOf <br /> v RVar-e� <br /> res city State P <br /> Phone Phone Email <br /> V <br /> i C b <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,Indicate type and license number <br /> r <br /> Address City State ZIP CIO <br /> Phone Phone Email <br /> ❑Billing Party ❑FaciNy Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP U <br /> Phone Phone Emah <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that ah 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 /> 1 also certify that I have prepared t i application and that the t be performed will be dare in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL I S. I`y Jj <br /> APPLICANT'S SIGNATURE: DATE: V "t <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title J <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 /> Accrt1d By Assi d.To Linked FA ID 11� ■fr <br /> W./I AIJ�(- Ja <br /> Dat� PE J �j Fee Recgr r ❑ <br /> Rev 05/12/2024 ` �•� }/Vl 1 o w l L-fN l�- �'l U 1 �� , ` 1EAT IRONM NTUNTM <br /> i 1 U I`f 12�P - '�a�P,vRr�ivr <br />