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Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />Application Form P £O5Hl°lS5 <br />Facility Name <br />State <br />^(Change of Owner Consultation Repairs or Remodel Other <br />5 - M - 2- <br /> Contractor Architect Billing Party Facility Owner Facility Contact Property Owner <br />'trilling Party ^Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberLast name <br />Email <br />C <br />t^Billing Party (^facility Contact Contractor^Facility Owner <br />If contractor, indicate type and license numberLast name <br />Phone <br />g Oi/V~X <br /> Contractor Architect Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />State ZIPCityAddress <br />Phone EmailPhone <br />—-A <br />DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER <br />Title <br />Fee <br />Confirmation H Check # Cash <br />IRev 07/10/2024 <br />1 <br />License Plate Number <br />Contact Types <br />required <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 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. <br />APPLICANT'S SIGNATURE: <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 />release of 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 />ZIP <br />ZIP <br />ZIP <br />S (q <br />First Name \ <br />O(TxV~\ <br />State <br />C.A <br />Em^il <br />C op S~~V \ A v\~V \ <br />Phone <br />Site Address <br />APN Supervisor District <br />---------- <br /> Facility Contact <br />First Name <br />Address <br />Phone <br />Address <br />Phone <br />2.0^Zoq <br />Linked FA ID <br />Record Number <br />Payment <br />Received By <br />City <br />\ Cc\C^j <br />City <br />Assigned To <br />_______ <br />cjr\~w. i \ <br /> Architect <br />Accepted By <br /><S<e < A ck______ <br />City <br />"V ( C'KC'y <br /> Property Owner <br />State <br />c A <br />PE <br /> Property Owner <br />Type of Service <br />Requested <br />Comments <br />CVc\A^ <br />If mobile food truck'©/ <br />pumper truck