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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Names(r o M(-Z— Pf G J cc— <br /> Site Address ``++ City State ZIP <br /> 2D s c t S <br /> APN Supervise District <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel Cl 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 ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor 11 Architect <br /> required <br /> Q i illne Party ❑Facility Owner ❑Facillty Contact ❑Property Owner L]Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> M 7— <br /> Address 'l City State ZIP <br /> C9,1t`'E <br /> Phone Phone Ernall <br /> d <br /> ❑Billing Party ❑Facility Owner 13 Fatility Contact 11 Property Owner ❑Contractor 0 Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Finail <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner i7 Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone --FEmail <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 laws. <br /> APPLICANT'S SIGNATURE: t�y(� !(eW C7 _ _ DATE: <br /> ❑PROPERTY BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT pjg� <br /> Title RF <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Nr <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner Or operator of the property located at the above site address,hereby 11 <br /> ' <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENWRONMENTALOPTI� O <br /> DEPARTMENT as soon as it Is available and at the same time it is provided to me or my representative. <br /> ff�� <br /> J <br /> Accepted By Assigned 1py L�G r� Linked FA ID 4;r/981 C0 <br /> � 1/� [; <br /> Date Iti— IJL� PE tYV Fee f� LA / c `2-4(1)r Z`iS TMFH <br /> Rev 06/12/2024 <br /> 1-��� �� <br />