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s <br />yL.New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address City State ZIP <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br />Property Owner Architect Billing Party Contractor <br /> Contractor Architect Billing Party Facility Owner Facility Contact <br />If contractor, indicate type and license number <br />State ZIP 752^0Q/F <br />Phone Email <br /> Contractor Architect Property Owner Billing Party Facility Owner Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />State ZIPAddressCity <br />Phone EmailPhone <br /> Contractor Facility Contact Property Owner Facility Owner Billing Party <br />Last nameFirst Name <br />CityAddress <br />YEmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGERPROPERTY / BUSINESS OWNER <br />Title <br />Linked PAIDAssigned ToAccepted By <br />FeePEDateWzi <br /> Check tl <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <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 />0 Application for <br />Operating Permit <br />irk to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Last name <br />''□cashL^__ <br />Rev 07/10/2024 <br />Type of Service <br />Requested <br />Comments <br />------- <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 <br />Standards, STATE and FEDERAL laws. f. <br />APPLICANT'S SIGNATURE: <br />I <br />/ <br />VINJAJbKF0L4T-CkJ/f 5005 <br /> Facility Contact <br />(^Property Owner <br />ensTmumber <br />________Application Form <br />Mg <2 A PA-L6TnA/ <br />J-?. 62 Ap/’ <br />Supervisor District <br /> Confirmation U <br />License Plate Number <br />| n'SQ'Z-Gl <br /> Facility Owner <br />First Name <br />QZSfrCCLX________ <br />Address , <br />?Z<9 g /ODI /lyg., <br />Phone Phone <br />|q If, <br />Payment ( X <br />Received ByV V-/ <br />If contractor, type and licensl <br />____$4^ ____