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4 <br />□ Existing FacilityNew Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />^5 O r* 1 V*5- S*F'Dbc)T" rvc4<- <br />Site Address City <br />APN <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />S^Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />Last name <br />I <br />Email <br />Q^Facility Contact□ Billing Party □ Facility Owner □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license numberFirst Name I <br />Address pa <br />Phone Email <br />□ Property Owner □ Contractor □ Architect□ Billing Party □ Facility Owner □ Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br />□ OPERATOR/MANAGER□ PROPERTY / BUSINESS OWNER <br />Linked FA IDAssigned ToAccepted By <br />□ Check #□ Cash <br />Rev 07/10/2024 <br />License Plate NumberIf mobile food truck or <br />pumper truck <br />□ Application for <br />Operating Permit <br />VIN <br />ZIP <br />^5330 <br />ZIP <br />State <br />Type of Service <br />Requested <br />Comments <br />Phone <br />Contact Types <br />required <br />^Billing Party <br />ell • co hn <br />J«-Tvvx.a^, <br />If contractor, indicate type and license number <br />State <br />3>SS~ AJCnvJd fly <br />Supervisor District <br />First Name ____ <br />Address , f -.piwb c ■- n ‘ Cp08 <br />Phone <br />HIT MIS I&3H <br />Last name <br />Goetrigfr S Hr-Z-I Cv^ <br />Phone <br />Reeordto1bAP2401041 <br />ZIP <br />o <br />State <br />0)4- <br />D3teqiaa4 <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 />I also certify that I have prepared this application and ttet theywork to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordi^^-tqdc', <br />Standards, STATE and FEDERAL laws. -------- f U^- 'h II Q I DU/ <br />APPLICANT'S SIGNATURE: JC DATE: /Z>' 7 <br />Mother authorized agent PrtS ?P j - <br />Title <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required ^/A/ ’ <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site addre^^r^^Q^wWO^ <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIR0NMENtA^^<J^'V7^^ <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.____________22^1 <br />City <br />FR. <br />^Confirmation tl <br />SB.____ <br />PEl(o01