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Existing FacilityNew Facility <br />San Joaquin County Environmental Health Department <br />APN <br /> Repairs or Remodel Other Change of Owner Consultation <br /> Contractor Architect Property Owner Facility Owner Facility Contact Billing Party <br />□^Facility Contact ArchitectEZBilling Party □"Facility Owner Contractor Property Owner <br />If contractor, indicate type and license number <br />City State <br />Phone ■> <br /> Architect Contractor Billing Party Facility Owner <br />If contractor, indicate type and license numberLast nameFirst Name <br />State ZIPCityAddress <br />EmailPhonePhone <br /> Property Owner Facility Owner Facility Contact Billing Party <br />Last nameFirst Name <br />StateCityAddress <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT 'OR/MANAGER•PEI <br />Title <br />Linked FA ID <br />IMkPE <br /> Check U Cash <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br /> Application for <br />Operating Permit <br />Payment <br />Received By <br />State <br />Type of Service <br />Requested <br />Comments <br />License Plate Number <br />UA'Fp <br />VIN <br />id that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />QzuL. <br />Address <br />City <br /> Contractor <br />If contractor. <br />Dtc o lzl2025 <br /> ^safety - _______________________________________________n^LrHDEj£j^l <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that anSffteWor 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 ^pplicafn <br />Standards, STATE and FEDERAL laws. \/V^1 <br />APPLICANT'S SIGNATURE: <br />^PROPERTY / BUSINESS OWNER <br />Application Form <br />Facility Narrjj^6 <br />Supervisor District <br />Record Number________ k APasOJ-AOCp <br />^Confirmation « <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 i s a v a i I able and at the same time it is provided to me or my representative. <br />Accepted By <br />Da,Mi |U ~ <br />Last name / 7 <br />1 Phone Email _ _, , / <br />b WWW' <br /> Facility Contact I Property Owner