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if New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form ne,,,}- nPez �(2- <br /> Facility Name <br /> City State ZIP <br /> APN Supervisor District <br /> Type of Service Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumpertruck yiV W3 Is yA9W l �✓� � <br /> Contact Types ❑Billing Parry ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party PTFacility Owner i2rFacility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicatetype and license number <br /> 61veviMRAN JIN4 44 <br /> Address City State ZIP <br /> l��Cry tw ByRoN R-n 'CV&Pr4y cia 9S30 <br /> Phone Phone Email <br /> ae�a}3�,-21►� 2oa p�e�o -tis�� �+". %t a <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor T � <br /> First Name Last name If contractor,indicate type a b r <br /> Address City State s, P, 1 �Q <br /> J I <br /> Phone Phone Email /tr�w N fly L, <br /> BILUNG ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator orauthorized agent of same,ackn owledge that all site a ject <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me a my business as identified on this <br /> farm. <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with a t I SA JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. (� <br /> APPLICANT'S SIGNATURE: �YC Li i DATE: 3!(d l a t <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,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 sametime it is provided to me or my representative. <br /> Accepted 4 By �,A Q Assigned To ��A��� l Unked FA I <br /> Date !2111 W PE �n+L fee <br /> 1 UUN ���a I Payment <br /> ❑Cash ❑Check Confirmation M � � R etewed#3y <br /> Rev 07/10/2024 U <br />