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1 <br /> ❑ New Facility ❑ Existing Facility: <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Nam6 LL-A A SRv eR S LA- <br /> Site <br /> AddrLL-0 �j SA�C�S�I� /\, iEN U� Clt� _QI �� State <br /> , <br /> APN Supervisor District �J ��/ 1�4J <br /> Type of Service ❑Appiication 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 ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> B r A <br /> illing Party El Owner ❑Facility Contact Property Owner ❑Contr ctar ❑Architect <br /> s <br /> First Name A ��r � Last e, �� � �� If contractor,indicate type and license number <br /> yA�dydr,sJ (9 CA RLTc^ l f �' J Cl j ( N 60 I N <br /> Phone <br /> l V L^ 5tat�, <br /> Ud[�' <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 Email <br /> ❑Billing Party ❑Facility Owner ❑Fatuity 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 Email <br /> BILLING ACKNOWLEDGEMENT.,1,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br /> form. <br /> I also certify that I have prepared this ication and t t the- ork to b p f ed_ II be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDER L I ws. r� A <br /> APPLICANT'S SIGNATURE: DATE! `! PA)e4 <br /> j# <br /> `[d PROPERTY/BUSINESS OWNER Q OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT CAI�D <br /> Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required ��QQ���� 0� <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site adAIN Or by auth�0e <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY EN��� �f 61 N <br /> DEPARTMENT as soon as it is available and at the same time it is provided tome or my representative. L �MOr� <br /> L <br /> Accepted By Assigned To Linked FA ID <br /> Date ot PE l �0� Fee �� r, Record Number <br /> i <br /> --// Payment <br /> ❑Cash fYCheck# 10911 <br /> O91f ❑Confirmation N Received ByM <br /> Rey 07/10/2024 1-) 31515 `J <br />