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Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />icillty Name <br />“’jwkZ” <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br />17bb <br /> Billing Party Facility Owner Property Owner Facility Contact Contractor Architect <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />Last name If contractor, indicate type and license number <br />Address ZIPState <br />-^3^ <br /> Billing Party Facility Owner Facility Contact Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone EmailPhone <br /> Billing Party Facility Owner Facility Contact Property Owner <br />First Name Last name <br />Address City <br />EmailPhonePhone <br />_ DATEf <br /> OTHER AUTHORIZED AGENT OPERATOR / MANAGER PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAssigned ToAccepted By <br />FeePEIGo3 <br /> Check # <br />Rev 07/10/2024 <br />Contact Types <br />required <br />Payment <br />Received By <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 />‘^^Confirmation tl <br />Type of Service <br />Requested <br />Comments <br /> Application for <br />Operating Permit <br />AZW A? ■ <br />If mobile food truck or <br />pumper truck <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-i O I I X / '7 <br />APPLICANT'S SIGNATURE: DATE;, U I ‘ <br />New Facility <br />LA/vg______TOvurgce <br />Phone MV —— <br />lAJ k-XTAHAVV'- <br /> Property Owner <br />□ Contractor V QlJlhitect <br />First Name \ <br />Date , . <br />'3/3/2 4 <br /> Cash <br />AT <br />Supervisor District <br />If contrac^iARdiftt^ license number <br />£' A <br />___________ <br />1557 <br />Phone ’