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Existing Facility New Facility <br />Facility Name <br />Site-Address City State <br />IAPN <br /> Repairs or Remodel Consultation Change of Owner Other <br /> Architect <br />Billing Party Facility Contact Property Owner Contractor Architect Facility Owner <br />Last name If contractor, indicate type and license number <br />i'A <br />Address <br /> Facility Contact Contractor Billing Party Facility Owner Property Owner Architect <br />First Name Last name If contractor, indicate type and license number <br />StateCity ZIPAddress <br />EmailPhonePhone <br /> Contractor Architect Facility Contact Property Owner Facility Owner Billing Party <br />If contractor, indicate type and license numberlast nameFirst Name <br />City State ZIPAddress <br />Phone EmailPhone <br />DATE: <br /> OPERATOR / MANAGER OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER <br />Title <br />Recor <br />Rev 07/10/202n <br />iigni <br /> Application for <br />Operating Permit <br />Email <br />h' a ^btr4 <br />Phone <br />773^77-4; <br />ZIP <br />Type of Service <br />Requested <br />Comments <br />______On St 4-< V-qmr <br />If mobile food truck or <br />pumper truck <br />ly'CO Gira/ij- Lac ?-V) <br />Phone <br />- '■ k - <br />die <br />City <br />License Plate Number ”7 <br />P Payment <br />I Received Bi <br />Tn z '''■‘■■■■I ■ , ' <br />i-n <br />\(c lu Wt p <br />VIN <br />___________________________________________ <br />Linked FA ID AUiPAOOQ^^I <br />-- T ..........l&KMSf <br />First Namez\ ] . i <br />(roP2^-CO! <br />Afla • <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, <br />release of any and all results, geotechnical data and/or environmental/site assessment Information to the SAN JOAQUIN COUNTY ENVIRONMENTAu(|§A <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />San Joaquin County Environmental Health Department <br />Application Form <br />\S~OQ E. Ctcnjfl-l ~Tr< <br />Supervisor District <br />State <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 />1 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 Ordinanit Cwf sL*-. <br />Standards, STATE and FEDERAL laws. A V-, 0 (1 ’"7 i 0 - '7 *4 <br />APPLICANT'S SIGNATURE:L. - /T I _________________________DATE: t ' I I <br />7/W <br />ContactTypes <br />required -■