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San Joaquin County Environmental Health Department <br />Aoolication Form <br />Facility Name <br />Site Address <br />APN <br />Other <br />Li< <br />□ Bill <br />^Billing Party I Architect <br />d license numberFirst Name <br />I <br />Address \*MI <br />ty Contact □ Property C <br />he <br />City <br />□ Property 0 <br />rame <br />fL <br />□ PROPERTY / BUSINESS OWNER □ OPERZ <br />Title <br />'o <br />Accepted By FA ID <br />Pitted/ <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />knowledge that all site and/or project <br />,e or my business as identified on this <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 />□ <br />Oj <br />SAN JOAQUIN COUNTY Ordinance Codes, <br />- - 24 <br />i <br />Type of Service <br />Requested <br />Comments <br />I <br />3 <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 lawi . <br />APPLICANT'S SIGNATURE: VA Cf, ZL Po <br />je-K G- <br />Tor <br />^00 <br />Su <br />- <br />* <br />ii <br />TWTIfl L-C <br />Dat®Q((p4(I Number <br />■ <br />■ <br />AKfike <br />H I -7 o <br />________ <br />□ Architect <br />■ <br />■ <br />r 1| City <br />> above site address, hereby authorize me <br />N COUNTY ENVIRONMENTAJ/^^IUtM . <br />- <br />y /a. <br />UjM^/ - <br />^74^ ^SL- ' (0 <br />i j <br />Si add <br />ir1 K z 1/