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Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />iAPN <br />^Change of Owner Consultation Other Repairs or Remodel <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Architect Contractor <br /> Billing Party p^Facihty Owner Facility Contact Property Owner Contractor Architect <br />First Name If contractor, indicate type and license number <br />1 ■ <br /> Billing Party Facility Owner Property Owner Contractor <br />■ i-si Name Last name <br />Address City State <br />Phone Phone Email <br />TY1 Billing Party Facility Owner Facility Contact Property Owner Contractor <br />First Name Last name <br />CityAddress State ZIP <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER <br />Linked FA ID <br />Fee <br />■■‘F»/12/2O24 <br />Contact Types <br />I lequired <br />APPLICANT is not the BILLING PARTY, proof of authorization tn sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner 01 opeialoi of the property located at the above site address, hereby authorize Hi • <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 piovided to me 01 my representative <br />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <br />City <br />State <br />Last name <br />ZIP <br />ZIP <br />State <br />0/1 <br />L\<\ V\ ca. e 5_______ <br />PE <br />\koQ2_/ Otp | <br />to'oZ U 5 <br />Address <br />1766 <br />Phone <br />Type of Service <br />Requested <br />Comments <br />Facility Name <br />Email <br /> Facility Contact <br />_____ <br />R"og^4®(DZ-Ti <br />Etfie <br />Phone <br />Site Address <br />/69 LffTHUbP HO <br />Supervisor District <br />i Accepted By <br />L 1 ■_ _ <br />| Date <br />'o-2i0-iq <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 Hu <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 Lode <br />Standards, STATE and FEDERAL laws. I I <br />APPLICANT’S SIGNATURE: DATE: /)£ 1 <br /> OPERATOR / MANAGER OTHER AUTHORIZED AGENT <br />Title <br />City <br />bOThHoP <br />Assigned To <br />Oo2- <br />l33>C^2-\ 15" <br />! Architect <br />If contractor, indicate type and Vfl 4 r* , <br />C(Q/ /* <br />________ <br />If contractor, indicate type and license numbei