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Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />zi??5ZO6 <br />o <br /> Change of Owner Repairs or Remodel Other Consultation <br /> Facility Owner <br />'fi Billing Party Property Owner Contractor Architect Facility Owner Facility Contact <br />If contractor, indicate type and license numberLastFirst <br /> Property Owner Contractor Architect Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPCityStateAddress <br />EmailPhonePhone <br /> Contractor Property Owner Facility Contact Billing Party Facility Owner <br />Last nameFirst Name <br />StateCityAddress <br />EmailPhonePhone <br /> OPERATOR/MANAGER PROPERTY / BUSINESS OWNER <br />Title <br />Assigned ToAccepted By UM <br />Feemz- <br /> Check« <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 ByT3 Confirmation # <br />Mwo <br />PE <br />Type of Service <br />Requested <br />Comments <br />Application Form <br />y'cv v _ <br />Supervisor District J 'APN <br />L,nkedfAl^/\ <br />j V.S o 0 ] I4\x\ j |. <br /> Facility Contact <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 work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standar^s^rMTandFEDERAL laws. » /I I I !'\ ' <br />APPLICANT'S SIGNATURE?\|\{\c>^(] ___________________________________ DATE: — -/ ' / _____________ <br /> OTHER AUTHORIZED AGENT <br />Wa. <br />VlGrfa_____ <br />SA fry'y <br />Rhone Phone <br /> Application for <br />Operating Permit <br />fcr ________ <br />v'kCPS^72^/721^ <br /> Facility Contact Property Owner Contractor <br />°ate4 i|^u> <br /> Cash <br /> Architect <br />If mobile food truck or I .License Plj. <br />pumper truck * | >3 S* <br /> Billing Party <br />If contractor, indic.iAYJyse and license nfirnber <br />-