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f.New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address � .� 44F 5 T 44/ �� C l� State ZIP �Ia 3 <br /> APN J Supervisor District (/'' S' (! <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel J7,0ther ,/ <br /> Requested Operating Permit r <br /> Comments ♦' S o/ Av/2 SO/C <br /> IYA All) A a6M dZ4 5 Apaxj to CEP ro.L r.f.v�cf s - � a <br /> If mobile food truck or Licerise Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner Contractor ❑Architect <br /> required <br /> Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner Contractor --T❑Architect <br /> First Name Last na9le If contractor,indicate type and lic nse number <br /> 1 l / �N. 5 CL <br /> Addr city State ZIP <br /> Phone Phone EmailA14 <br /> Billing Party14OQacility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> Fir Name Las m ..> If contractor,indicate type and license number <br /> 1� S,t a� /.1L <br /> Address � w� Ci ,. State ZIP <br /> Z S� G �i vc�/o�✓ �i zfl3 <br /> Phone Phone Email <br /> U Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> F' t Name_ '?Q� La q� /Ar If contractor,indicate type and license number <br /> Addre t <br /> Ci D� Sta(/�7 <br /> Phone � P one 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 /> 1 also certify that I have prepared this applica and a work t performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. —� <br /> APPLICANT'S SIGNATURE: DATE: j <br /> ❑PROPERTY/BUSINESS OWNE OPERAT /MA Cl?�THER 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 Linked FA ID 4!^000 //c/ <br /> Date '/ PE Z C 4 1 O 3 Fee Record Number j�/©7 GG, <br /> '-I <br /> ❑Cash ❑Check# Confirmation# Payment <br /> Received By <br /> Rev 07/10/2024 rr,A 2 c10:3e1 cf 6 5 7 <br />