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San Joaquin County Environmental Health Department <br />AoDlication Form <br />Facility Name <br />Site Address <br />APN Su <br />Li< <br />□ Bill □ Architect <br />^Billing Party I Architect <br />d license numberFirst Name <br />I <br />Address <br />□ Property Cty Contact <br />ne <br />City <br />□ Property 0 <br />City <br />□ OPER/□ PROPERTY / BUSINESS OWNER <br />Title <br />FA IDAccepted By <br />SAN JOAQUIN COUNTY Ordinance Codes, <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />If APPLICANT is not the BILLING PARTY, proof of auth <br />AUTHORIZATION TO RELEASE INFORMATION: Wher <br />release of any and all results, geotechnical data and/ <br />DEPARTMENT as soon as it is available and at the sai <br />Tor-h <br />^oo <br />□ <br />Of <br />ame <br />L <br />Type of Service <br />Requested <br />Comments <br />U/nlH I -7 Px o <br />BILLING ACKNOWLEDGEMENT: I, the undersigned pro] <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hour1 <br />form. <br />I also certify that I have prepared this application and ’ <br />Standards, STATE and FEDERAL law^ . . <br />APPLICANT'S SIGNATURE: VA <br />3 <br />!i;nowledEe that al1 site and/or project <br />x ie or my business as identified on this <br />cJ^/^lity Contact <br />G. <br />I I <br />y a <br />" A-A v <br />/^uS'r <br />2 above site address, hereby authorize the <br />N COUNTY ENVIRONMENTAi/c/iUTM . <br />I Number <br />2<-l (2)G> <br />/vKAf TI/( C6 <br /> ^S/oc, <br />(Lc^ <br /><' fc- "7 2 2-01