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San Joaquin County Environmental Health Department <br />-t <br />APN <br /> Repairs or Remodel Other Consultation Change of Owner <br />License Plate Number VIN <br /> Contractor Architect Facility Owner Billing Party <br /> Contractor Architect Facility Owner Facility Contact Property Owner Billing Party <br />If contractor, Indicate type and license numberLast name <br />State <br />Pi <br /> Contractor Architect Property Owner Billing Party Facility Owner Facility Contact <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPCityStateAddress <br />EmailPhonePhone <br /> Architect Property Owner Contractor Facility Contact Billing Party Facility Owner <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPCityStateAddress <br />EmailPhonePhone <br />/ f DATE: <br /> OPERATOR/MANAGER PROPERTY / BUSINESS OWNER <br />Linked FA IDAssigned ToAccepted By <br />Date <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 />releaseof 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 />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 applicatloi <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />City <br />Email <br />ZIP <br />4,s~ <br />Site Address <br />Supervisor District <br />/7Z- <br />Type of Service <br />Requested <br />Comments <br />Record Number. k _, <br />tt=^ <br />Application Form <br />/ state ZIP <br />CXFacillty Contact I Property Owner <br />1 X______I ____ <br />First Name <br />Address <br />Phone PlrOi <br />id that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />HER AUTHORIZED AGENT ‘ C <br />Title