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❑ New Facility IV <br /> Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form PpOkOV903 <br /> Facility Name <br /> Site Address D Lae � � City�� State CA ZIP C/ 5 e-7 o <br /> APN Supervisor District <br /> LJ -/f <br /> Type of Service ❑Application for ❑Consultation Change of Owner 0 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 illing Party acllity OwnerI/N'rillty Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Nb'n Facility Owner Klacility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last ream If contractor,indicate type and license number <br /> J�q �i n � <br /> Address U City State ZIP <br /> ILI,. S'-t o C.I-'tb rn <br /> Phone 66ne Email <br /> O - 0 F rL v 1IVA <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact operty Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> 5 C- <br /> Address f)a City e?oe' '��; SiCe4 ZIP <br /> Phone Y 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 Email <br /> BILLING ACKNOWLEDGEMENT:I,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 applic i and that the work to be performed will be done in accordance with a115A JOAQU�},C'O�UNTY OrdinanStandards,STATE and cJl�ades •ry.�- <br /> APPLICANT'S SIGNATURE: DATE: <br /> laws. DATE: a`"^ �•• ����� i <br /> PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER El OTHER OTHER AUTHORIZED AGENT +�9 i)s �D <br /> Title ����`` j I <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required SA& <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,her b <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONM <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. T Nr <br /> Accepted By Assigned To Linked FA ID <br /> v " gne use F 7D <br /> Date r y PE + Lo 02— Fee tr � ' O� Record Number <br /> LQ2.-- ,fC6(4 CZ( C��A(A- 2, <br /> _7� <br />