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Ca <br /> New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />P^2. I <br />Facility Name <br />Site Address w <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br />VINLicense Plate Number <br /> Facility Contact Property Owner Contractor Architect Billing Party Facility Owner <br /> Property Owner Contractor Architect Facility Owner Facility Contact Billing Party <br />If contractor, indicate type and license numberFirst Name <br />StateAddress <br /> Architect Contractor Property Owner Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPCityStateAddress <br />EmailPhonePhone <br /> Contractor Property Owner Facility Contact Facility Owner Billing Party <br />Last nameFirst Name <br />StateCityAddress <br />2EmailPhonePhone <br />un <br />iws. <br />/DATE: <br /> OTHER AUTHORIZED AGENT I ] OPERATOR / MANAGER PROPERTY / BUSINESS OWN! <br />Title <br />Accepted By <br />PE (U03 <br /> Confirmation it Check II <br />Rev 07/10/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />If APPLICANT is not the BILLING PARTY, p ooTof authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMA ION: 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, geotechnics 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 /> Application for <br />Operating Permit <br />BILLING ACKNOWLEDGEMENT: I, tl <br />specific ENVIRONMENTAL HEALTFl/ <br />form. / <br />I also certify that I have prepared this api lie <br />Standards, STATE and FEDERAL <br />APPLICANT’S SIGNATURE: ___. <br />Type of Service <br />Requested <br />Comments <br />Application Form <br />City- 7^ fC State, <br />JHrL <br />1T1I4 <br />Phonef <br /> Architect <br />If contractor, indii^^yp/e number <br />ZIP^S3^ <br />Sfp <br />iersigned property or business owner, operator or authorized agent of same, acIcl^l^Jte^W^^lWreeT^I/or project <br />iEPA tTMENT hourly charges associated with this project or activity will be billed to me or my b’•4/?>|D’*lentified on this <br />ion and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Linked FA IDFAQ>q>28l2X> <br />Record Number <br />Payment ( / <br />Received By <br />Supervisor District <br />Email / , <br />i vWe W <br /> Facility Contact <br />Phone <br />S^Cash <br />Last name <br />^Assigned To