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M/New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> a Facility Name <br /> Romaine rA+er r ; <br /> Site Address City State ZIP <br /> CA 9S <br /> AP Supervisor District <br /> Type of Service WApplication for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments C n C C f-� <br /> q <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required Contact Types ❑Billing Party ❑Facility Owner ❑ <br /> Billing Party 5rFacility Owner ErFacility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Te Last 4m <br /> If contractor,indicate type and license number <br /> o tiAn c.(NJ <br /> Address City State ZIP <br /> S '.'j.s S W o U <br /> Phone Phone mail <br /> '1610 <br /> S-(n25 ci4 H <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Own r ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone -7Em ail <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor PA rt�e,�.. <br /> First Name Last name If contractor,indicRIEGEIVE01ber <br /> Address City State AUG19 2024 <br /> Phone Phone Email SAN JO QUIN COUNTY <br /> EWJ ONMENTAL <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 DEP TMENT hou es 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 prepay d nd that a work to ormed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDE <br /> APPLICANT'S SIGNATURE: DATE: <br /> ❑PROPERTY/BUSINESS OWNER ❑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 /> Accepted By Assigned To 1 Linked FA ID <br /> Date � . � A PE ���� Fee ,{.; � Record Number <br /> `t `4tJt / o Payment <br /> ❑Cash ❑Check# �]confirmation# l Y ZS b 4 �� Received By <br /> Rev 07/10/2024 ( I y� A CC j tD 0 1J <br /> pR 2�l n03 g l <br />