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San Joaquin County Environmental Health Department Application Form Facility Name H/)QTRwdniNi flConHiltatlon O Change of Owner □ Repair* or Remodel □ Other license Plate Number VIN □ Billing Party P Facility Owner OFaaHy Contact O Property Owner □ Contractor □ Architect □ Facility Owner□ Billing Party □ Facility Contact □ Contractor □ Architect□ Property Owner If contractor, indicate type and license number □ Architect□ Contractor□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner If contractor, indicate type and license numberFirst Name last name State ZIPAddressCity EmailPhonePhone □ Contractor □ Architect□ Facility Contact □ Property Owner□ Facility Owner□ Billing Party If contractor, indicate type and license numberlast nameFirst Name State ZIPCityAddress EmailPhonePhone DATE: □ OTHER AUTHORIZED AGENT □ PROPERTY / BUSINESS OWNER O OPERATOR / MANAGER Title Assigned To Record NumlPE Contact Types required If mobile food truck or pumper truck 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 HEALTH DEPARTMENT as soon as It Is available and at the same time it is provided to me or my representative______________________________________________ □ Application for Operating Permit Email I S' o i I- c City RI POaI Site Address J/?l k). r7Z)|N APN ZIP City LlbiCQLrA State cz? Last name State C/1 Phone Type of Service Requested Comments r ____________ Supervisor District First Name Address 295 WOlN Phone ^16-5)9'trill ___ "'feR.-ZBCAQm ri -y 2025 •ntified on this f tou ” i TJ PE BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site a..-,-, fJ fJ'’- 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. Standards, STATE and FEOERAl laws. , C- / APPUCANTS SIGNATURE: DATE: ?*) [ IQ [ ■*- -2.-----------------------