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❑ New Facility lxxisting Facility <br /> (needs SR#) <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name LAry I <br /> Site Address O City 1^ State ZIP clJb2,R <br /> APN (� L Supervisor District 1 <br /> Type of Service ❑Application for ❑ Consultation ❑ Change of Owner ❑ Repairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ® Billing Party ❑ Facility Owner ®Facility Contact ❑ Property Owner IM Contractor ® Requester <br /> required <br /> filling Party •acility Owner ❑ Facility Contact ❑ Property Owner wtractor ❑ Architect <br /> r <br /> First Name Last nam7� If contra or, indicate type and license number <br /> Address � ,n ,� C'�y State ZIP <br /> Pho� Phone , + V Bail <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 /VJF� <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑Arch t ct i J 026 <br /> J <br /> First Name Last name if contractor,indicate e <br /> Ew l <br /> Address City State ZIP E <br /> Phone Phone Email <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 a cats n nd that thew k to be pert rmed will be done in accordance with all SAN JO QUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERA laws. / , 2 <br /> APPLICANT'S SIGNATURE: DATE: N^ <br /> ❑ PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER If <br /> OTHER AUTHORIZED AGENT !_/ <br /> Title <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required C t�rdr 1'' <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 /> Accepted B Assigned T—� I Linked FA ID <br /> 1 LS �/y�"! ry m3i98 <br /> Dat PE Fee Record Number <br /> � 2Z ff 24' 2� �l 51(Z a <br /> 13 �� / 7 7 Payment <br /> ❑Cash ❑ Check# Confirmation# / Received By <br /> Rev 07/10/2024 2 of 6 <br />