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[$ Existing Facility□ New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />^Change of Owner□ Consultation □ Repairs or Remodel □ Other <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />Billing Party Facility Owner OS Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license number <br />Email <br />□ Property Owner □ Contractor □ Architect□ Billing Party □ Facility Owner □ Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />State ZIPAddressCity <br />EmailPhonePhone <br />□ Contractor□ Properly Owner□ Facility Contact□ Billing Party □ Facility Owner <br />First Name Last name <br />StateAddressCity <br />EmailPhonePhone <br />md l.at <br />□ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGER□ PROPERTY / BUSINESS OWNER <br />Title <br />Accepted By <br />2oC ^7-0 g,□ Check it <br />Rev 07/10/2024 <br />City <br />If mobile food truck <br />pumper truck <br />VIN <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 />Last name <br />Cku..'AO O <br />City <br />ZIP <br />ZIP <br />r AG Z-O G <br />State <br />C- -G ■ <br />State <br />Type of Service <br />Requested <br />Comments <br />Linked FA ID <br />Record Number <br />First Name <br />Address <br />Phone <br />0Confirmation it <br />□ Application for <br />Operating Permit <br />k or License Mate Number ’ <br />Gm <br />ie work to be performed will be done in accordance with all SAN JOAQLjlN COUNTY Ordinance Codes, <br />________________________________ DATE: O& /g/S <br />PypPsfiL Q UO <br />Phone <br />rz O WT >•> G> <br />/ Facility Name <br />/ L <br />/ Site Address <br />, GzbO g C <br />APN <br />If contractor, indicate tyfJ^W^/^^gwjiber <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that aH^t^a^iFr 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. V>, <br />I also certify that I have prepared this application <br />Standards, STATE and FEDERAkJaws. <br />APPLICANT'S SIGNATURE: / <br />I Contact Types <br />required <br />□ Cash <br />Supervisor District <br />"•iW i > '