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□ New Facility □ Existing Facility <br />San Joaquin County Environmental Health Department <br />c'tvRtmm ^7 ft <br />Supervisor District <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />VIN ft 32-^ 2- <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />M Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name Last name If contractor, indicate type and license number <br />Address State ZIPa <br />Email <br />□ Billing 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 />□ Facility Contact □ Property Owner □ Contractor□ Billing Party □ Facility Owner <br />Last nameFirst Name <br />City StateAddress <br />EmailPhonePhone <br />and 'work to beit <br />DATE: _ <br />PROPERTY / BUSINESS OWN.□ OTHER AUTHORIZED AGENT □'ERATOR / MANAGER <br />Title <br />Linked FA IDAssigned ToAccepted By <br />F C <br />or□ Check ti□ Cash <br />Rev 07/10/2024 <br />Contact Types <br />required <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 />If mobile food true! <br />pumper truck <br />^Billing Party <br />Type of Service <br />Requested <br />Comments <br />Record Number <br />Payment <br />Received By <br />If contractor, indicat^(pp< <br />^5— <br />________________________________________________________ _______________________________ <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 applicatp <br />Standards, STATE and FEDERAL laws^-— <br />APPLICANT'S SIGNATURE: / /^-^l <br />rPhone Phone <br />TtWefi'Won <br />□ Application for <br />Operating Permit <br />uci. or License Plate Number L <br />\and license r <br />Application Form <br />APN 1 <br />irmed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />6A l ift) | <br />2^Confirmation it <br />Cu. GO