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Existing Facility New Facility San Joaquin County Environmental Health Department Application Form Facility Name Site Address City State Lp\) I APN Consultation Change of Owner Repairs or Remodel Other License Plate Number VIN Billing Party Facility Owner Facility Contact Property Owner Contractor Architect Q'Facility ContactK/Billing Party Property Owner Contractor Architect ff- City c Facility Owner Facility Contact Contractor Architect Last name Phone Facility Contact Contractor Billing Party Facility Owner Last nameFirst Name Address City State Phone Phone Email DATE: OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER Title Accepted By Fee Check tt Rev 07/10/2024 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 M Facility Owner C,O- Oco ^^Confirmation tt Type of Service Requested Comments ■wrrtraetor.-indicate type and license numbex-" ccc ZIP Phone ✓"___________ 0 Billing Party Date I,1-01-3 5 Cash State GA City UloocAbr\d' Assigned To T'r^nc'i^co K- sm_____ Linked FA ID FA 0) CT 3.1 Record Number SR. 1-50 17 00 Payment Received By lo't (g 7 Supervisor District Email f oo' \-Aa A • Property Owner First Name 7fr(Z^-€SA___________ Address Phone 7Q7-37V-WI ■ Property Owner Last nam.‘ \Mcd p. ZIP ^5^40 •tf- cun li dCt’Ol,indicate type and license-number— /iMSf Leg^ccj LLC 45^52 I Architect BAxMEto___ If contractor, indj6itaj,yoe and ffcPnsv ftumber RECEjvpd ZIP D£c I 1 2025— _______Z_____ _______ ______________ BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, ‘jfpa/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my businesS3vidMBlW3'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 FEDERAL laws, j j - APPLICANT'S SIGNATURE: DATE: ; ! 1 ' > First Name Address . z. ., . Lh> Phone State