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❑ New Facility G Existing I acillty San Joaquin County Environmental Health Department A pplication Form _ Facility Name VJl L G, yr Cit ZIP Sate Address x State i APN Supervisor District Type of Service ❑Application for ❑ Consultation ❑ Change of Owner ❑ Repairs or Remodel I U Other Requested Operating Permit — — -- --- -�-----_-_-.. _- ------�1---- -- Comments If mobile food truck or License PI to Number ViN I I pumper truck ---- - - -- Contact Types ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑Architect i required [ 'Billing Party ❑ Facility Owner O Facility Contact ❑ Property Owner ❑ Contractor I ❑Arch feet ! Last name If contractor, indicate type and license number I First Name _ ,V fCA r t-(-�G j j �nr etl-,-c... l c u v L% Address City State ZIP Phone Phone Email —� ❑ Billing Party @,rcility Owner ❑ Facility Contact ❑ Property Owner f ❑ Contractor ❑ Architect First Name Last name If contractor, indicate type and license number City State ZIP Address P .one Phone Email I I i ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑Architect I j— Last name If contractor, indicate type and license number 1 First Name City I State ZIP 1 Address I j Phone Phone Email BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or protect specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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, j Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: 3 DATE: Z PROPERTY/ BUSINESS OWNER OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT iNl��a'` ` " ✓ _._.-___ S ❑ S Title I j If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required pplicable, I, the owner or operator of the property located at the above site address, hereby au:honte the AUTHORIZATION TO RELEASE INFORMATION:When a release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENI AL HLALI I+ i } 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 ID PE Fee Record Number ; � Date i I Payment ❑ Cash ❑ Check 9 ❑Confirmation 4 Receiveo By Rev 07/10/2024