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□ New Facility San Joaquin County Environmental Health Department Facility Name atm l‘“fA ZIP APN K/change of Owner □ Repairs or Remodel □ Other□ Consultation License Plate Number □ Contractor□ Facility Owner □ Facility Contact □ Property Owner □ Architect□ Billing Party 'jf_______________ QTacility Contact[XFacility Owner □ ArchitectiVBilling Party □ Property Owner □ Contractor If contractor, indicate type and license number Email □ ArchitectEfFacility Contact □ Contractor□ Property Owner□ Facility Owner If contractor, indicate type and license numberLast nameFirst Name J Phone □ Architect□ Contractor□ Facility Contact□ Billing Party Last nameFirst Name City StateAddress EmailPhonePhone ST■X □ OTHER AUTHORIZED AGENT / MANAGER□ OPERA.□ PROPERTY / BUSINESS OWNER Title Assigned ToAccepted By PE I foOJ □ Check fl□ Cash Rev 07/10/2024 If mobile food truck or pumper truck Contact Types required □ Application for Operating Permit Payment Received By 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._______________________________________________ 'V1(> Rh A Phone . Phone (^^Confirmation U Type of Service Requested Comments Linked FA ID Record Number 5olk________fterson □ Property Owner H^Existing Facility ------------ □ Facility Owner If contractor, indicate type and license number the undersigned property or business owner, operator or authorized agent of same, acknowled^A/l/)V(5^ / healthirk to be performed will be done in accordance with all SAN JOAQUIN COlWr ____________________DATE: /X/ " Fee5l^ / ’""-"CorllK □ Billing Party you ___________________________________________________ ZOff— BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledt’A/^VOi’ft^W^01' Proiect specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my busg^VF/^ f°rrn- // / I also certify that I have prepared this application and thaML/e wc/rk to be performed will be done in accordance with all SAN JOAQUIN COUm^-(^/«7T^£^ys, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: L3Stname£tL'S Pi.-dr1/sen Application Form a*s 5; Supervisor District ’ / State ,