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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />State <br /> Consultation Change of Owner Repairs or Remodel Other <br />License Plate Number VIN <br />Billing Party Facility Contact Property Owner Facility Owner Contractor Architect <br />Billing Party Contractor Architect Facility Owner Facility Contact Property Owner <br />If contractor, indicate type and license number <br />State ZIP <br />Phone <br /> Contractor Architect Facility Contact Property Owner Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />City State ZIPAddress <br />EmailPhonePhone <br /> Contractor Architect Property Owner Facility Contact Facility Owner Billing Party <br />Last nameFirst Name <br />StateCityAddress <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER <br />Title <br />Accepted By i <br />Date <br />i <br />If mobile food truck or <br />pumper truck <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 />Type of Service <br />Requested <br />Comments <br />Application Form <br />Site Address <br />APN <br />Last namc5 O <br />Ci,v <br />If contractor, indicate type jLT <br />zip <br />- <br />sia,JO2, <br />_____________________________________________________________________________ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all siteWiOZqi^rMett <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified onthlV? <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 Codes, <br />Standards, STATE and FEDERAL laws. Q-i A A) f <br />APPLICANT’S SIGNATURE: / DATE: <br /> OPERATOR / MANAGER <br />FlrstNameg? ; <br />•"ynya <br />tyWyl" UzC.'g- l-T^ oo I mT <br />op <br />if TA 77. <br />Supervisor District