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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form f i-z\y <br />IO lY\g4 <br />kl <br />dnjhange of Owner Repairs or Remodel Other Consultation <br />Q <br />License Plate Number VIN <br />^^Billing Party "^Facility ContactIg^Facility Owner Property Owner Contractor Architect <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <br /> Facility Owner Facility Contact Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor U <br />First Name Last name <br />Address StateCity <br />Phone Phone Email Hl <br /> OTHER AUTHORIZED AGENT <br />Title <br />Accepted By Assigned To <br />FeeDate \^-2 <br /> Cash Confirmation « <br />Rev 07/10/2024 <br />Contact Types <br />required <br /> Application for <br />Operating Permit <br />Payment <br />Received By <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 HEALT H <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />State <br />State <br />City ZIP <br />City <br />Em I <br />t^Check ft <br />DATE: 2 <br />Type of Service <br />Requested <br />Comments <br /> Property Owner <br />If mobile food truck or <br />pumper truck <br />Facility Name <br />VUWe- <br />Site Address <br />2-2U <br />APN <br />25 | <br />(hcM- L\xve rd <br />Supervisor District <br />Record Number8(3-250) U<p\ <br />First Name <br />In­ <br />Address ’ , <br />mi kj <br />Phone . <br /> Billing Party <br />If contractor, indicate type and license numfltiCU/ <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 law^Z y // <br />APPLICANT'S SIGNATURE: --------- <br />^y^OPERTY / BUSINESS OWNER OPERATOR / MANAGER <br />Lgst-name <br />Lifm. _________ <br />Pfione 1 “ "