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❑ New Facility LH Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> a.Faci'iftytNome 4 <br /> A���G, C a�•C ; ��," s�� <br /> AI O.Oress L 'Rate pp <br /> CA <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation IrChange of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or E4-Ae tO�K^41mbeY' VIN <br /> J <br /> pumper truck 7-3�, Z2 <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> e ,n� <br /> lWng Party �f4 i ttontacf ❑Property Owner ❑Contractor ❑Architect <br /> First Name ''ll Last name t If contractor,indicate type and license number <br /> V M��tTO Q� �C'�-`e� <br /> Address r J � � Avg City^ �6� State� A ZIP � <br /> Phone Phone Email `� 'L►1 J <br /> 3� <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 a41a I-S a �T <br /> Address City State ZIP <br /> A <br /> Phone Phone Email SAN <br /> JOAQUIN <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that a i PRR.4Rp ct <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on <br /> form. <br /> I also certify that I have prepared this applic on nd that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL la <br /> I-o1� <br /> ���-siGwuYu.y�: - � rE: BLS <br /> ❑PROPERTY/BUSINESS OW ER ❑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 S h a.n n o rn 2). Assigned To n I au n I a M. <br /> . Linked FA ID <br /> Date- 19 , a 5 PE 1 o a Fee f RecordNumber <br /> g00 q 3 4 <br /> ❑Cash ❑Check# Confirmation# � z� Q/, Payment <br /> (U s—c�l� Received B7ffr <br /> i <br /> Rev07/10/2024 T( OSgiS3+ <br />