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❑ New Facility I Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form FRO SL -12-(q <br /> Facility Name ] ! <br /> L <br /> Site Address City ` State ZIP <br /> APN Supervisor District <br /> Type of Service ❑Application 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 _ e� <br /> pumper truck ZY'/U< (; 7 1 -Z- HXI-< <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner El Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor -T❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> AIC4& <br /> Address _ City _ _ State ZIP /,/ <br /> i O S�/L-e U 1<,e /'�/ S iC7C�C >c"/v /19 % <br /> Phone 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 Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractorrinftItAR icense number <br /> RFCFiifcn <br /> Address City State <br /> TV— <br /> Phone Phone Email <br /> SAN JOAQUIN COUNTy <br /> hNVIRONMFNT,Ai _ <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same, Zl4QEFM Tr'd/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 application and that the to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: /2 <br /> ❑PROPERTY/BUSINESS OWNER OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is 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 /> Accepted Byr Assigned To Linked FFyA�ID <br /> �2 t C L G, c: 1 F f l\000-4 vo <br /> Date PE Fee Record Number <br /> 12 j I Z 1,202 Kpob �I�'2- <br /> Payment <br /> L(!'Cash ElCheck q ❑Confirmation# Received By <br /> ell— <br /> Rev 07/10/2024 �� <br />