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New Facility Existing Facility San Joaquin County Environmental Health Department Application Form Rev 07/10/2024 Facility Name Site Address City State ZIP APN Supervisor District Type of Service Requested Application for Operating Permit Consultation Change of Owner Repairs or Remodel Other Comments If mobile food truck or pumper truck License Plate Number VIN Contact Types required Billing Party Facility Owner Facility Contact Property Owner Contractor Architect Billing Party Facility Owner Facility Contact Property Owner Contractor Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email Billing Party Facility Owner Facility Contact Property Owner Contractor Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email Billing Party Facility Owner Facility Contact Property Owner Contractor Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project 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 FEDERAL laws. APPLICANT’S SIGNATURE: __________________________________________________________ DATE: ________________________________ PROPERTY / BUSINESS OWNER OPERATOR / MANAGER OTHER AUTHORIZED AGENT ______________________________ Title 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. Accepted By Assigned To Linked FA ID Date PE Fee Record Number Cash Check # Confirmation # Payment Received By oyett Petroleum # CA 95 0 x CGRS, Inc Matt Thomas 5444 Dry Creek Road Sacramento CA 95838 626-627-8316 916-991-1100 mthomas@cgrs.com same A/HAZ 803616 Compliance Services Manager - CGRS 202