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San Joaquin County Environmental Health Department <br />Application Form <br />City <br />Supervisor District <br />□ Consultation XA Change of Owner □ Repairs or Remodel □ Other <br />License Plate Number VIN <br />tSl'Facilily Contact□ Facility Owner □ Property Owner □ Contractor □ Architect <br />Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />Last name If contractor, indicate type and license number <br />Phone <br />□ Billing Party □ Facility Owner □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license number <br />City State GADr. <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor <br />rFirst Name Last name <br />Address City State <br />I PhonePhone Email <br />DATE: <br />□ PROPERTY / BUSINESS OWNER □ OPERATOR/MANAGER <br />Assigned To <br />PE Fee <br />TO] <br />Type of Service <br />Requested <br />Comments <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />□ Application for <br />Operating Permit <br />ZIP <br />ZIP <br />ZIP <br />ScGo I <br />Last name <br />Facility Name <br />Site Address <br />Email <br />P G LU I Af/YTh <br />D'Facility Contact <br />jot term i <br />hi <br />AS8 GsooclajiG) Dr. <br />APN <br />State <br />CA <br />IsZBilling Party <br />First Name <br />Address <br />AGS Gscodujin <br />Phone | Phone <br />3^-339-3111 <br />First Name <br />> 11 <br />Address <br />it~1~1 S. q*-* A-ve <br />Phone <br />1 SI} <br />£ l ipo n <br />State <br />Gp <br />City <br />I i CcxH <br />1 Accepted By f * <br />Date r PE <br />Email <br />u"kedF,ID^-/4oo2.^^4 <br />Record Number <br />SRZSO) II5\__________I_______________ <br />PJL 173- CO Gs^. <br />□ Archita^t^ <br />If contractor, indicate type and <br />______________ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on ItiflKS’/hy <br />form, <br />I also certify that I have prepared this application and that LhevVork to be performed will be done In accordance with all SAN JOAQUIN COUNTY Ordinance Codes. <br />Standards, STATE and FEDERAL laws. /T f i i • r cl <br />APPLICANT'S SIGNATURE: <. ZT^X • G' -"'A, DATE: I <br />(3 OTHER AUTHORIZED AGENT Ad. O-U''] ~h-/V-V A S’? 1 5 te<J'\d’ <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 />Wpsi/ io