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0 11 New Facility 14 Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ontractor L— i Site Address Last name If contractor, indicate type and license number Cit State ZIP Address City State ZIP APN vel 2--11L Supervisor District Phone Email —_ Type of Service W.pplication for ❑ Consultation ❑ Change of Owner ❑ Repairs or Remodel ❑ Other Requested Operating Permit Comments If mobile food truck or License PI to Number VIN pumper truck Contact Types Milling Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ntractor ❑ Architect required illing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ontractor ❑ Architect First Name Last name If contractor, indicate type and license number t, -v— 164c,t tm L C-� C Y\ �r c. C iL?� LR C, u U o Address City State ZIP vel 2--11L hone Phone Email —_ ❑ Billing Party 514cility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect First Name Last name If contractor, indicate type and license number Address ',1 Z CA c,A-C ` 1 o v 9,,k City State C a ZIP 915 - -- P one Phone Email vel 2--11L lc(�"u-tats t —_ ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect First Name Last name If contractor, indicate type and license number Address City State I ZIP Phone Phone Email 31LLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this 7orm. 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, standards, STATE and FEDERAL laws. 4PPLICANTS SIGNATURE: DATE: 12 -30 Z j ❑ PROPERTY / BUSINESS OWNER OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT _InAA -- 'kT✓ -- Title If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HLALI II DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Accepted By Assigned To Linked FA 10 Date PE Fee Record Number ❑ Cash ❑ Check # Payment ❑ Confirmation # I Received By i Rev 07/10/2024