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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br /> Consultation Change of Owner Repairs or Remodel Other <br />License Plate Number VIN <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 number <br />€ <br /> Billing Party Facility 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 /> Billing Party Facility Owner Facility Contact Property Owner <br />First Name Last name <br />Address City State <br />Phone EmailPhone <br />£3^DATE: <br /> OPERATOR/MANAGER OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA ID <br />nt <br />Rev 07/10/2024 <br />I <br />^•2500521 <br />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <br />Contact Types <br />required <br />ZIP7^70^ <br />ZIP <br />Assigned To / ' <br />---/U.ACkZA.V <br />^^Confirmation tl <br />Type of Service <br />Requested <br />Comments <br />Email <br />re 7 <br />\ S'- <br />□ Facility Contact1 <br />Supervisor District <br />First Name wA 1 <br />Address <br />72 G <br />Phone <br />' Payment <br />Received By <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 and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. / / / z '-J <br />APPLICANT'S SIGNATURE: Z/ (< G DATE: -/ - /) <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 y it is available and at the same time it is provided to me or my representative. <br /> Cash <br />Facijly-Wame <br />Site Address <br />3^ S c q \ j fo a t CK <br />APN 1 I f-------’ <br />’a <br />: Property Owner <br />City . <br />S-|oc <br />riw^w <br /> Check tt <br />Last name <br />r4 <br />Cp\Q Cc <br />Phone <br /> Contractor * <br />If contractor, indXu^ tytfe endJicense number