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ffl/ New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Site Address.State <br />0 <br />APN Supervisor District <br /> Consultation Change of Owner Repairs or Remodel Other <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />/ Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />First Name If contractor, indicate type and license number <br />I Address State ZIPQ.<4 .9rz/z <br /> Contractor Architect Billing Party Facility Owner Facility Contact Property Owner <br />If contractor, indicate type and license numberFirst Name Last name <br />State ZIPAddressCity <br />Phone Phone Email <br /> Contractor Facility Contact Property Owner Billing Party Facility Owner <br />Last nameFirst Name <br />StateCityAddress <br />Phone EmailPhone <br />hl <br />DATE:/^ <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER <br />Title <br />Accepted By <br />PE <br />Ct <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 By <br />ZIP <br /> Check tl <br />Type of Service <br />Requested <br />Comments <br />a. y <br />Email <br />7=T, 0 uih C co *15 <br />If mobile food truck or <br />pumper truck <br />[ A/’ r <br />^130 y. <br /> Architect <br />If contractor, indicat <br />M____________________________________________________________ M/, <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge WSVn4 s|U jfHd/or project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as idwfi^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 />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />a <br /> Cash <br /> Application for <br />Operating Permit <br />License Plate Number U '■ VIN (/ v ' <br />Confirmation U <br />'FI t'a <br />3 oo s' L-e/i no <br />Phone I Phone <br />7') <br />Record Number <br />ZIP x-x^5 <br />Last name .Tl 4 a <br />Fee