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Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Site Address <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name <br />Address <br />Phone <br /> Facility Owner Facility Contact Billing Party Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br /> Facility Owner Facility Contact Property Owner Contractor Architect Billing Party <br />Last nameFirst Name Hr <br />City StateAddress <br />EmailPhonePhone <br />les, <br /> PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA ID <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />Payment <br />Received By <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 />/hJOAUjQ <br />Email <br />----------- <br />1^/6 DjLchOA <br />Phone <br />ZIP <br />State ZIP <br />Ml <br /> Check tt <br />State <br />-CXL <br />Type of Service <br />Requested <br />Comments <br />\JZ] Confirmation tt <br />Pl^New Facility <br />Assigned To » \ <br />|A(ai <br />l&TL <br />VIN <br /> Application for <br />Operating Permit <br />Accq U/t F p r ( C1 K <br />License Plate Number <br />Facility Name P/7/IZ -J/I R I <br />~7.7o CjA'JerynM St <br />Supervisor District <br />“SB <br /> Cash <br />City <br />City <br />a50 a5 83, <br />2-og <br />Last name, <br />If contractor, indicate type anffrQiyJjyter <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowle <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my busitreZ^^g-i^^Jj^is <br />form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAbJaws. .. c, jc 3 C <br />APPLICANT’S SIGNATURE: JA/TL&'h DATBr' f " J <br /> OPERATOR / MANAGER OTHER AUTHORIZED AGENT