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Existing Facility <br />Application Form <br />Facility Name <br />Site Address <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br /> Contractor Architect Facility Owner Facility Contact Billing Party <br />If contractor, indicate type and license numberFirst Name <br />Address <br /> Contractor Architect Property Owner Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />State ZIPAddressCity <br />PAYMENTEmailPhonePhone <br /> Property Owner Contractor Facility Owner Facility Contact Billing Party <br />Last nameFirst Name <br />City StateAddress <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT [S PROPERTY / BUSINESS OWNER OPERATOR/MANAGER <br />Title <br />Linked FA IDAssigned ToAccepted By <br />Fee <br /> Cash <br />Rev 07/10/2024 <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 /> Application for <br />Operating Permit <br />Payment <br />Received By <br />City <br />Last name <br />City <br />ZIP3521^ <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^xr/ \ X <br />APPLICANT'S SIGNATURE: DATE: _> Z-Qg <br />VIN <br />Phone <br />Qw 327-5TC.^ <br />State <br />State <br />CA <br />License Plate Number <br />^Confirmation it <br />^New Facility <br />San Joaquin County Environmental Health Department <br />Type of Service <br />Requested <br />Comments <br />Zz <br />S CcrAcuX <br />Phone <br />10(20*5____ <br />M Go'tidi Aue <br />Supervisor District <br />*7____________ <br />PE^ /V5 <br /> Check II <br />ReeordNumber <br />_________ <br /> Facility Contact <br /> Property Owner <br />Date <br />JtrRrfhGrU <br />If contractor, indxl^^ypl eSd niirnber <br />SA^JOAQQ|^[COIiiut-w <br />heal