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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Addresp City State ZIP <br /> u S. cw,t ( �04 6 L)< <404 <br /> APN /S 1 S3 qL)3 Supervisor District <br /> Type of Service ❑Application for XConsultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <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 Zlp <br /> 0 S. til ;lSc�✓J (� o �n <br /> Phone Phone Email <br /> O C <br /> Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner Contractor El Architect <br /> First Name I- st name <br /> G If contractor,indicate type and license number <br /> AddresskA City State ZIP <br /> �o Sri l L o <br /> Phone Phone Email <br /> c ell` z <br /> U07). non <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 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 I w . <br /> APPLICANT'S SIGNATURE: �/y / �7, DATE: -3z' w -- <br /> ❑PROPERTY/BUSINESS OWNER El OPERATOR/MANAGER OTHER AUTHORIZED AGENT C/'!2 & L A <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <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 /> Accepted By , Assigned To70- Linked FA ID <br /> Date I ,1 L Z PE 7 9 Fee 7 Record Number <br /> ❑Cash ❑Check q ❑Confirmation q '(� �� �0 Payment <br /> Received By <br /> Rev07/10/2024 <br />