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New Facility 8 Existing facility <br />FadfltyNamr <br />State <br />aJ <br />APN <br /> OtherH.Ch.tn80 ol Owner Repairs o' Remodel Consultation <br />VINlicense Plate Number <br /> Architect ContractorPlFacility Owner Facility Contact Property Owner Billing Party <br /> Architect Dilling Party ContractorjRjacility Owner Facility Contact Property Owner <br />First Name if contractor, indicate type and license numberLast name <br />Address ZIPState <br /> Architect Property Owner Contractor Facility Owner Facility Contact <br />First Name If contractor, indicate type and license numberlast name <br />Address City ZIPState <br />Phone Phone Email <br /> Property Owner Contractor Billing Party Facility Owner Facility Contact <br />First Name last name <br />StateAddressCity <br />EmailPhonePhone <br />DATE: <br />/^PROPERTY / BUSINESS OWNER OTHER AUTHORIZED AGENT <br />Assigned To <br />Fee <br /> Cash Check « <br />Rev 07/10/2024 <br />San Joaquin County Environmental Health Department <br />f|2.OSM 2. SO <br />It 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 sue address, hereby authorize the <br />release of any and all results, geotechnical data and/or environmental/slte 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 />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <br />Payment <br />Received By <br />.Contact Types <br />required <br />Site Address <br />_2=£U <br />Application Form <br />£>£Lsi Pl'Zi-fi &IT& <br />Type of Service <br />Requested <br />Comments <br />Phqne <br /> Billing Party <br />FfcR Th t s to Nt /J/? / <br />Phone <br />City <br />Accepted By <br />PE\-2.<e,-zto <br />c"V/?/rcyTiMcy <br />Supervisor Dlslntl <br />linked FA IQ <br />1=A'00'2t-t,3>o2. <br />Record Number <br />^2.001^2^ <br />^Confirmation a "2\ 5 M M T <br />if contractor, indicate type an <br />_________________________________________ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that alrTo/A <br />specific ENVIRONMENTAL HEALTH DEPARTMENT houdy charges associated with this project or activity will be billed to me or my business as identified on this *’ • <br />form <br />l 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 / LsJl I I T^Sl 2- Z <br />APPLICANTS SIGNATURE: K ________________________________ DATE: / I ° <br />□ OPERATOR/MANAGER □ OTHER AUTHORIZED AGENT (2. E <br />Title