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Ok) ❑ New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Faei#ity Name LC <br /> 0 <br /> Site Address City State ZIP <br /> �� <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types N Billing Party IT Facllity Owner CYl Contact ElProperty Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party 7acility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIPC <br /> (-�l lco <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Emak <br /> 11 Billing Party ❑Facility Owner CJ Facility Contact ❑Property Owner ❑Contractor —ite�cl. <br /> First Name fast name If contractor,indicate t.. nrhr15er <br /> Address City State q <br /> N JOA <br /> Phone Phone Email ly,�4L H1?0 /NCpV BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all �r project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me of my business as identif(ed on this <br /> farm. <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, l . i R l <br /> APPLICANT'S SIGNATURE: ✓1/6. Il DATE: i 2 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <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 HEAL <br /> DEPARTMENT as soon as it is available and at the some time it is provided to me or my representative. <br /> Accepted By Assigned To L- U`1-A Linked FA ID <br /> T r Nu <br /> Date PE 1�x-7- <br /> �k e O <br /> ElCash ❑Check q Confirmation H2 D x Payment <br /> u Received ey <br /> Rev 07/10/2024 P0,25 a)I(A` � <br />