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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> e0A1,rV61b(6 Ckall?04 - 111141 Gr EM E <br /> Site Address City State ZIP <br /> a, wEs r ws RD , rkEdifY MMP4 <br /> APN Supery or District <br /> R3- - 4/4 .3 q67 <br /> Type of Service ❑Application for B"Consultation ❑Change of Owner ❑Repairs or Remodel X Other <br /> Requested Operating Permit <br /> Comments <br /> SS III L R 6 V, - yy <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner 12'Facility Contact 8'Property Owner E"Contractor ❑Architect <br /> required <br /> OBilling Party GerFacility Owner [facility Contact OProperty Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> A 04 6t <br /> Address city State ZIP <br /> a-I A FA 5 i Li4 S T-AEG 0 v Oj <br /> Phone Phone Email <br /> 2- t <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ontractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Dad RCE e-15-47-1 <br /> Address Cit State ZIP <br /> 0• t349K 3 7,f 4- GtRLOGIL <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor, i nse number <br /> Address City State I <br /> PD <br /> Phone Phone Email 2026 <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of sam T nd/or project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed trr My 9ATA"Tied on this <br /> form. <br /> I also certify that I have prepared this Aon'an:;��e <br /> ormed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 4 b, G <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER V OTHER AUTHORIZED AGENT cI UI L F,Lqe <br /> Title <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 /> Accepted By Assigned To Linked FA ID <br /> Date <br /> umbe <br /> 7(�LG PE 01 o� Fee "71( I� Rgco d N��� I�J <br /> Payment <br /> ❑Cash P Check# j ❑Confirmation# Received By <br /> Rev 07/10/2024 <br />