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s <br />□ Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name KM I NG <br />APN <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />o\a. <br />Billing Party Facility Owner ^Facility Contact □ Property Owner □ Contractor □ Architect <br />^Billing Party Q Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address State ZIP <br />■Co <br />□ Billing Party □ Facility Owner □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br />□ Property Owner□ Billing Party □ Facility Owner □ Facility Contact !_ei <br />First Name Last name <br />Address City <br />Phone Phone Email <br />DATE: <br />□ OTHER AUTHORIZED AGENT □ PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAssigned ToAccepted By <br />Date <br />TP□ Cash <br />Rev 07/10/2024 <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 />Payment <br />Received By <br />Phone <br />Type of Service <br />Requested <br />Comments <br />□ Check tt <br />K-a olo iilr <br />CornrriQcUrc <br />Email <br />□ Facility Contact <br />fyau-y" <br />City <br />Spotc/ad <br />4 <br />Hartan <br />Supervisor District <br />JX Application for <br />Operating Permit <br />License Plate Numbc' <br />/08>2_q <br />Phone <br />If mobile food truck or <br />pumper truck <br />VIN <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 tlwthe work.to.bjj>erformed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> DATE: <br />□ OPERATOR/MANAGER <br />Zl 4^330 <br />To f' <br />City <br />’^Confirmations 2-|^ | | <br />Site Address .14-2-0/ <br />CHI^i <br />New Facility <br />□ Contractor ‘JU 1__J ,________ <br />^jontractor, indicate type ejid license number <br />;e Plate Number <br />/