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❑ New Facility XExisting Facility <br /> i <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility <br /> cnity Name <br /> ,O�n <br /> Site Address (�\ City State ZIP <br /> 5 OCD CD <br /> SupervisorDistrict <br /> Type of Service ❑Application for Monsultation ❑Change of Owner ❑Repairs or Remodel I jcner <br /> Requested Operating Permit j <br /> Comments ` <br /> v30rk= <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 ❑Ardiltect <br /> required <br /> Pilling Party ❑Facility Owner &F tility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First amp ` Last name If contractor,Indicate type and license number <br /> �e. ss�a,ur,ne-r- <br /> Address City State ZIP <br /> 00 S. 2P o t U.�Q 202 S+OCArj <br /> Phone Qp 40-) Phone 'mall <br /> �1�`�S7 z4o6�9`E3 I�nt,;sstaa�rner <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor rchltect <br /> eons tk(+a y1+ <br /> First Name Las name �T . \ If contractor,Indicate type and license number <br /> d332 TG(Z � eENTrGR- DZ. 4 100 l ,!+-1ress 5R�_��M State lip <br /> ��� <br /> Phone Phone dt-Ill I Email+=r..f in <br /> fl 3 2a3K33 QI�v--517^2122 <br /> ❑Bllling 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:1,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 1 have prepared th a 9kcatiorz an_l that the worliAobe er rmed_will-be done in accordance withpll SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL law j <br /> � / ' ,^�_ <br /> APPLICANT'S SIGNATURE: DATE: <br /> � <br /> Deputy Direct. Stockton Metr Apt. <br /> OOROPERTY/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 c Linked FA ID <br /> Date PE Fee cri Record Number <br /> `-2 <br /> ❑Cash ❑Check N WConfirmation it J v 1 /- t Payment <br /> F�� Received By <br /> Rev 07/10/2024 <br />