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San Joaquin County Environmental Health Department -I <br />Facility Name <br />Site Address <br />Supervisor District <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ other <br />VIN <br />Shilling Party □ Facility Owner □ Faculty Contact □ Property Owner □ Contractor □ Architect <br />MBilling Party □ Facility Owner O Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license numberLast name <br />State eft <br />□ Billing Party □ Facility Owner □ Contractor □ Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />ZIPAddressCityState <br />EmailPhonePhone <br />□ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect□ Billing Party <br />If contractor, Indicate type and license numberFirst Name last name <br />State ZIPAddressCity <br />EmailPhonePhone <br />DATE <br />[^PROPERTY / BUSINESS OWNER □ OPERATOR / MANAGER □ OTHER AUTHORIZED AGENT <br />Linked FA IDAccepted By <br />Re^ordJ^um^gr^Fee <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <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 a^d that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />Date <br />-tll' <br />Crty <br />Aslis' <br />______C)l,-3k^A_ <br />Title <br />□ Application for <br />Operating Permit <br />License Plate Number <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign Is required J* rs, <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authc^u^Ae^/b'/Ox'U/^ q <br />releaseof any and all results, geotechnical data and/or envlronmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEAL1Tr‘'^Z. MLy r-\ FNTV <br />DEPARTMENT as soon as it Is available and at the same time it Is provided to me or my representative. r~. 'L'Al '_________r^Nr <br />Application Form <br />ial /V <br />223-110-ld SupervisorDi5*rictt <br />Type of Service <br />Requested <br />Comments <br />□ Property Owner <br />!’P<l533^ <br />Hot Name <br />a/ (jiaxZlW' Av-L <br />□ Facility Contact <br />Assigned To 1 * i 111 ■ <br />I,rc]-553i