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San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br />License Plate Number VIN <br /> Billing Party Facility Owner Property Owner Facility Contact Contractor Architect <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />First Name If contractor, indicate type and license number <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />EmailPhonePhone <br />DATE: <br /> OPERATOR / MANAGER OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAssigned ToAccepted By <br />FeePEl«W <br />ZIP <br />Type of Service <br />Requested <br />Comments <br />Application Form <br />Supervisor District <br /> Application for <br />Operating Permit <br />If mobile food truck or <br />pumper truck <br />1466. <br />zipqs3^§ <br />Phone * , I-7© T-659-613(= <br />S.a.e <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 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. A A . <br />APPLICANT'S SIGNATURE: S»'\ V\ V \/\ DATE: <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 fw V <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAtX^K1^ n I <br />DEPARTMENT as soon asjt is available and at the same time it is provided to me or my representative. <br />Record Number wflP2.qqxj)4'5'3 J <br />Add,es5W <br />Phone <br />Citvfns2.cE£) <br />State <br />CA <br />last name