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Existing Facility□ New Facility <br />Application Form <br />APN <br />K Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />HH MFF <br />License Plate Number VIN <br />□ Facility Contact □ Property Owner □ Contractor □ Architect□ Billing Party □ Facility Owner <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, Indicate type and license number <br />State <br />'53'^ <br />□ Billing Party □ Facility Owner □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />State ZIPAddressCity <br />EmailPhonePhone <br />□ Property Owner □ Contractor□ Facility Contact□ Billing Party □ Facility Owner Hr <br />Last nameFirst Name <br />City StateAddress <br />EmailPhonePhone <br />. DATE: 22 <br />□ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGER□ PROPERTY / BUSINESS OWNER <br />Title <br />Fee. <br />□ Check «□ Cash <br />Rev 07/10/2024 <br />Supervisor District <br />City <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 />□ Application for <br />Operating Permit <br />le work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Type of Service <br />Requested <br />Comments <br />If mobile food truck or <br />pumper truck <br />Accepted By <br />Confirmation tl <br />San Joaquin County Environmental Health Department <br />Assigned To Linked FA ID <br />Record Number <br />5^3.50.149? <br />Payment <br />' Received By <br />7 _ Di/: <br />Phone Email <br />(^3^3 L Co <br />□ Facility Contact <br />If contractor, indicate typejnw/jjt^ljhgibir <br />S^JQ. .___ <br />___________________________________________________ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site 5iWfi)|^oject <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/tmyapplication <br />Standards, STATE and FEDERA^aw/' <br />APPLICANT'S SIGNATURE^