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New Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address City ZIP <br />APN <br />^Change of Owner Consultation Repairs or Remodel Other <br />License Plate Number VIN <br /> Billing Party Facility Owner Property Owner Contractor Architect Facility Contact <br />S Facility Owner Property Owner Contractor Architect <br />If contractor, indicate type and license numberLast name <br />State ZIPC4 <br />•co^/ <br /> Contractor Architect Facility Contact Billing Party Facility Owner <br />If contractor, indicate type and license numberLast nameFirst Name <br />City StateAddress <br />Phone EmailPhone <br /> Contractor Facility Contact Property Owner Facility Owner Billing Party <br />Last nameFirst Name <br />City StateAddress <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT OPEI PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAssigned ToAccepted By <br />FeePE <br /> Check II Cash <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: 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, geotechnical 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 />Payment <br />Received By <br />Type of Service <br />Requested <br />Comments <br /> Property Owner <br />Application Form <br />Supreme Meat- Market <br />39A N- i-Aarv\ Ln. Suite [Q3 <br />Supervisor District <br />□f^Existing Facility <br />brancisco R. <br />^Confirmation # <br />State <br />CA <br />.J^fy^^wer <br />% <br />Hl Billing Papy <br />First Name /-T /<- <br />Address 7 /r* / <br />XT/ZL/ CT <br />©Facility Contac^ A <br />BILLING ACKNOWLEDGEMENT: I, the undersigned propeAy or <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hoilly/hargr <br />form. / f\, <br />I also certify that I have prepared this application anil that <br />Standards, STATE and FEDERAL laws. \ UJ <br />APPLICANT’S SIGNATURE: .___ _/ <br />C. <br />U//.LZW0 <br />mweZTi <br />FA 00/ggSI <br />Record Number <br />39.260^^9 <br />f- - - =isiness owner, operator or authorized agent of same, acknowledge that all sireQtfijtetproject <br />associated with this project or activity will be billed to me or my business as identified on this <br />fwork (o be performed will be done in accordance with all SAjtf JOAQUIN^iOUNTY Ordinance Codes, <br />- mte: <br />f^NAGER <br />I ZIP <br />If contractor, indicate type