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C 0A 1 -fir r=� C,1 '5,+ ❑ New Facility ❑ Existing Facility San Joaquin County Environmental Health Department Application Form P 5� G\ o i Facility Name iC1 C3J L��2_�� [ Site Address 1 �{A� ^+ / } �� StateO, ZIP C APN Supervisor District L` 1 J Type of Service ❑Application for ❑Consultation C3 Change of Owner El Repairs or Remodel Q Other Requested Operating Permit Comments If mobile food truck or License Plate Number VIN pumper truck Contact Types 17 Billing Party ❑facility Owner ❑Facility Contact ❑Property Owner ❑Contractor D Architect required ❑Billing Party ❑facility Owner ❑Facility Contact C3 Property Owner ❑Contractor ❑Architect First Name 3 Last name If contractor,indicate type and license number �k Address i`�„ �/� n f_ CJCI�}v1 f State CA ZIP Phone J 'IPPhollnetlT Email l l J "30`3 8 - 13 ❑Billing Party E I Facility Owner ❑Facility Contact E7 Property Owner ❑Contractor ❑Architect First Name Last name if contractor,indicate type and license number Address City State IF, Phone Phone Email ❑Billing Party ❑FacilftyOwner ❑Facility Contact 0 Property Owner Q Contractor ❑Architect First Name Last name If contractor,ind �[y number Address City State r Sf p D Phone Phone Email JOA o O` BILLING ACKNOWLEDGEMENT:I,t un erslgned property or business owner,operator or authorized agent of same,ac I. C or project specific ENVIRONMENTAL HEALT EPA TMENT hourly charges associated with this project or activity wil3 be billed to me or my 6t��entlfied an this f43TM. HT I also certify that I have prepare this ap lic On and that the work to be performed will be done in accordance with all SAN JOA UIN COUNTY Ordinance Codes, Standards,STATE and FEDERAL ws, APPLICANT'S SIGNATURE: pArE: V v ❑PROPERTY/BUSINESS OWN OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT Title If APPLICANT Is not the BILLING PARTY,p I.. .f authorization to sign Is required AUTHORIZATION TO RELEASE INFORMA ON: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,geotechnic 4 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. Accepted By 4!AigneQ To Linked FA ID Q•/)4 FA IX 0 Z 8 I'2-.ro Date I PE l l4 O 3 fee l].f� Record Number � "1 " � SRas4)kScD3 Payment Cash ❑Check H ❑Confirmation N Received Rev 07/10/2024 i L✓;