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Facility Name <br />/6Z <br />Site Address <br />APN <br />^Consultation Change of Owner Repairs or Remodel Other <br />License Plate Number VIN <br /> Facility Owner Facility Contact Property Owner Contractor Architect Billing Party <br />©'Billing Party Contractor Facility Contact Property Owner Architect Facility Owner <br />If contractor, indicate type and license number <br />StateAddress <br />Phone <br /> Contractor Property Owner Architect Facility Owner Facility Contact Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />State ZIPCityAddress <br />EmailPhonePhone <br /> Contractor Architect Property Owner Facility Contact Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />State ZIPCityAddress <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR / MANAGER <br />Title <br />Linked FA IDAssigned ToAccepted By <br />Record NumberFee <br />5 <br />PR 2. <br />San Joaquin County Environmental Health Department <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <br />C Mu.ro <br />4$ 350 <br />Type of Service <br />Requested <br />Comments <br />Supervisor District <br />ZIP <br />Application Form <br />ZIP <br />7^20^ <br />City <br />s. Wj2uxX^ <br />"sis^ |PE ibia <br />5//^- 5|3iK <br />First Name s’(’ f <br />^737 Ar/Zc/ <br />Phone J ... -- .sjA Phone Email <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 add^| <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRQ <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />Last name <br />' City^Z-^cX^/^^ <br />BILLING ACKNOWLEDGEMENT: 1, 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 application ajid that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws/^2 \ S s') ~ PT — / <br />APPLICANT'S SIGNATURE: — DATE: ------—----/-Jy+xYg-j. <br />^PROPERTY / BUSINESS OWNER OPERATOR / MANAGER OTHER AUTHORIZED AGENT <br />hereby au <br />State <br />CA