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San Joaquin County Environmental Health Department <br />Facility Name Ph <br />Site Address State ZIP ^5^34 <br />APN <br />□ Repairs or Remodel □ Other <br />VIN <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />IJ^Facility Owner□ Billing Party □ Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license numberTHI <br />State ZIP | q <br />Email <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address City State ZIP <br />Phone Phone Email <br />□ Billing Party □ Contractor□ Facility Owner □ Facility Contact □ Property Owner <br />First Name Last name <br />Address City State <br />Phone Phone Email <br />DATE: <br />□ OTHER AUTHORIZED AGENT □ PROPERTY / BUSINESS OWNER <br />Title <br />Accepted Bi <br />□ Confirmation it Received By <br />Rev 07/10/2024 <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 />Contact Types <br />required <br />□ Application for <br />Operating Permit <br />Last name <br />✓CTChange of Owner^consultation <br />_ i i <br />License Plate Number <br />c h t m <br />Type of Service <br />Requested <br />Comments <br />Co. <br />Assigned To <'1 0. <br />Fee - ‘Record Nurpber <br />Application Form <br />4311 HcU on* CqI <br />Supervisor District <br />Address <br />5^6^ \A/4VU <br />. Phone Phone ' <br />2-0 V <br />Cltv vFbc kK*' <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and^A^bject <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. « . <br />APPLICANT'S SIGNATURE: A 4________________ <br />□ OPERATOR/MANAGER <br />□ New Facility Existing Facility <br />If mobile food truck or <br />pumper truck <br />If contractor, indicate type and <br />°31e'4(^-0 <br />□ Check tl