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FJ New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> ' e-e <br /> Site Address City State ZIP <br /> W 1 �106 G C G� -o <br /> APN Supervisor District <br /> Type of Service _WApplication for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> v+J y2— <br /> If mobile food truck or License Plate Ni5mber VIN pumper truck -j"� ( -r�l T-1 A A 7, irzmo�o i.-JA <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ling Party jrFacility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last nam if contractor,indicate type and license number <br /> o <br /> Address State ZIP S! i SS r Y City City - 5lo <br /> Phone Phone Email <br /> 20 q Sla <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner Q Contractor ❑Architect <br /> First Name Last name it contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party Q Facility Owner ElFacitity Contact ❑Property Owner ❑Contractor L <br /> First Name Last name If contractor,indic tape nd licens er <br /> S,d a. <br /> Address City State Oq ZIP <br /> Phone Phone Email py <br /> Q�p RNP,q� fl' <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 nd that the work to be performed will be done in accordance withpall SW JO/pOUIN COUN rdinance Codes, <br /> Standards,STATE and FEDERAL fa J / G <br /> APPLICANT'S SIGNATURE: DATE: 11 l <br /> F,KROPERTY/RUSMESS OWNER ❑OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the above site address,hereby authorize the <br /> release of arty 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 8y Assigned T linked FA ID <br /> Ca 1-tl Date — PE Feet Respr p]r}�et )I p <br /> Payment <br /> ❑Cash Check ft 1 ofdl ❑Confirmation ft Received By <br /> Rev 07/10/2024 �� /] r± O� <br />