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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address <br />/2/q <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />Billing Party Facility Contact Property Owner Contractor Architect <br />First Name Last name If contractor, indicate type and license number13 <br />( H lM <br /> Billing Party Facility Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor <br />First Name Last name <br />Address City State <br />EmailPhonePhone <br />6- ^-20^DATE: <br /> PROPERTY / BUSINESS OWNER OTHER AUTHORIZED AGENT <br />Accepted By Assigned To <br />2Z <br />Rev 07/10/2024 <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 />Date <br /> Cash <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <br />Payment <br />(eceived By <br />ZIP <br />Title <br />City <br />'^Facility Owner <br />ZIP <br />^^■7 <br />" type and liCer^^yrnl <br />Type of Service <br />Requested <br />Comments <br />State <br />C(X <br />State <br />CA <br />icatiomend that tj»e work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> OPERATOR / MANAGER <br />Fee UY^ <br />\-\eoq__________ <br /> Property Owner <br />circle- <br />Email > <br />__hem-hunn <br /> Facility Contact <br /> Check # <br />Address <br />5G3£ Str <br />Phone <br />^0-777-7370 <br />Phone <br />_________Application Form <br />Bracket <br />W Jlarch /r? <br />Supervisor District <br />If contractor, indicate tVPe and liderfe/ijnber <br />1/1 <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. <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: ---------- <br />Linked FA ID <br />Record Number <br />^Confirmation# (^2^2-Re