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New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> � �.(- it >rtI <br /> Site Address n t City State ZIP <br /> � a <br /> APN Supervisor Ilistrict <br /> Type of Service Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> �ie�� MFF C.o��•.\t�.�;ev� (Sc�cra Cs,un+y) <br /> p mobile food truck or License r1Plat�yu r`t� VIN I(� <br /> pumper truck Olt <br /> X 1/ <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> I Billing Party n Facility Owner Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name I- name If contractor,indicate type and license number <br /> Address C'ty State ZIP <br /> Phone Phone Email <br /> S\ -.8 <br /> ❑Billing Party ❑Facility Owner ❑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 ❑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 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 nd t the ork to be performed will be done in accordance with all�AN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL { ( q `�-7 <br /> APPLICANT'S SIGNATU �� DATE: L� PAYAw <br /> T <br /> ❑PROPERTY/BUSINESS OWNER ❑OPE OR/MANAGER ❑ I�ecOTHER AUTHORIZED AGENT D <br /> Title A n�j <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required �I P Q q <br /> ?172AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above sib dress,hereTiy �ize the <br /> E�}release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY HEALTH <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. h/ RC)I1J (2�N <br /> Accepted By Assigne_`d To Linked FA ID NT <br /> jeFF C L U SA <br /> Date PE Fee Record Number <br /> •3�Cirz� ��a13 1 2.m� I'12- t9-0ZSVBg3 <br /> Payment <br /> Cash ❑Check# ❑Confirmation# Received By <br /> Rev 07/10/2024 215�'R 3q0 <br />