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<br />I <br />"'I^Existing Facility New Facility <br />Facility Name <br />ZIPStateCityc/) <br />APN <br /> Other Repairs or Remodel I Consultation <br />VINLicense Plate Number <br /> Architect Contractor Property Owner Facility Contact■ Facility Owner Billing Party <br /> Architect Contractor Property Owner Facility Contact Facility Owner Billing Party <br />If contractor, indicate type and license numberlast nameFirst Name <br />ZIPState ^3^ ICd <br /> Architect Contractor Property Owner Facility Contact® Facility Owner Billing Party <br />If contractor, indicate type and license numberFirst Name <br /> Architect Property Owner Facility Contact Facility Owner Billing Party <br />If contractor, indicate type and licenseLast nameFirst Name <br />ZIPStateCityAddress <br />EmailPhonePhone <br />7y <br /> DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR/MANAGERCB PROPERTY / BUSINESS OWNER <br />Title <br />Fee <br /> Check R Cash <br />RevOZ/lO/ZOZ'l <br />If mobile food truck qr <br />pumper truck I <br /> Application for <br />Operating Permit <br />Contact Types <br />required <br />Payment <br />Received By <br />ZIP <br />If APPLICANT is not the BILLING PARTY, proof of authoriiation 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 authoriie the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DE PARTMENT as soon as it is available and at the same time it is provided to me or my representative._________________________________________________ <br />^Change of Owner <br />Type of Service <br />Requested <br />Comments <br />Phone <br />Accepted By <br />Date <br />Last name <br />City <br />________Me <br />Assigned To <br />U \ r\W^S <br />San Joaquin County Environmental Health Department <br />Application Form f05 <br />Phone Email(3) , <br />- Wzl Fa esh • <br />^5 3^^ <br />Address, <br />Phone <br />^L <br />Address . <br />Phone Phone Email <br /> Contractor <br />__ _ <br />PE <br />_______ <br />State cA <br />V)_____________ <br />City <br />.^.^8 <br />BILUNG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that al^i£i*ah^f Q; <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business <br />form EPAa-.J'1- <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 />UnWfAiD _rFooiMfeog <br />Record Number <br />S ^2.(^0 22,^ <br />^Confirmation l> 2,2.2,^ S I fa <br />jLimonO S'uSKj----------- <br />Site Address . , „ . <br />Supervisor Dinrict