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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />ZIP <br /> Consultation Change of Owner Repairs or Remodel Other <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />VgTJ’Hing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />ZIP 76^/ <br />Phone <br />at. <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 <br />Phone Phone Email <br /> Billing Party Facility Owner Facility Contact Property Owner <br />First Name Last name <br />Address City <br />Phone Phone Email <br />IATE: <br /> OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER <br />Title <br />Assigned To <br />Fee <br />I <br /> Check tl <br />Rev 07/10/2024 <br />Contact Types <br />required <br /> Application for <br />Operating PermitII <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 />Date <br /> Cash <br />JOAQUIN COUNTY Ordinance Codes, <br />Confirmation # <br />Type of Service <br />Requested <br />Comments <br />___________Application Form <br />C)u^ 6>o Suacd £2.(L <br />&c/c l'd <br />Supervisor District <br /> OPERATOR/MANAGER <br />) Gos <br />work to be performed will be done in accordance with all S/VM JOAQUIN CO1 <br />( C -kA <br />If mobile food truck or <br />pumper truck / <br />First Name / <br />■ Idress itate <br />Last name- /? / >% <br />Address / <br />Phone <br />^^16-01-^ <br />Site Address <br />APN <br />Accepted By-^ <br />PE <br />Linked PAIDAPaG)03043 <br />Record Number <br />JJcenseJ-yte Number <br /> Contractor <br />____ S4* <br />If contractor, <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 />I also certify that I have prepared this applicatioi <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />PaYment OZA_-- <br />Received By / /