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S^Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address ZIPState <br />61 <br />APN <br />S^hange of Owner Consultation Repairs or Remodel Other <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br /> Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />State <br />Phone <br /> Billing Party Facility Owner Contractor Architectierty Owner <br />If contractor, indicate type and license numberFirst Name Last name <br />Address State ZIPCity <br />Phone Phone Email <br /> Property Owner Contractor Billing Party Facility Contact <br />First Name Last name <br />StateAddressCity <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER <br />Title <br />Assigned ToAccepted By <br />CP Check tl Cash <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <br />ired this application and that tne <br />kL laws. <br />Date <br />^^Confirmation II <br /><^77 <br />Type of Service <br />Requested <br />Comments <br />^Facility Owner <br /> OPERATOR / MANAGER <br />If APPLICANT is not the BILLING PARTY, proof of authorization to signts 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 />Contact Types <br />required <br />sfBilling Party S^acility Contact <br />^2^-7 <br />Pef-P C. <br />PEikoa <br />-/zj lAtTv <br /> Facility Contact Pt'opt <br />irk to be performed will be done in accordance wteh all sAn JOAQUIN COUNTY Ordinance Codes, <br />I | 7 / <br />Application Form <br />Supervisor District <br />Last name/'First Name <br />^wne^ Phonq/ <br />Linked FA ID . <br />Record NumberI sMwnw <br />Received By <br />4^ <br />If contractor, indicatejtype and licensfrtia’rjber <br />OR n <br />iroperty or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />iuJixeharges-associated with this project or activity will be billed to me or my business as identified on this <br />BILLING ACKNOWLEDGEMENT: I, theyndeuift <br />specific ENVIRONMENTAL HEALT>K5EPARTMEI <br />form. <br />I also certify that I have pp <br />Standards, STATE anfkFEDE <br />APPLICANT'S SIGNATURE: <br />I Facility Owner <br />L\jdLia Ba Ker <br />Fee4ri~n