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❑ New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name ! <br /> GC<;d LA�� <br /> Site Address City � State � � ZIP <br /> APN Supervisor District <br /> c <br /> Type of Service ❑Application for El Consultation Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party acility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> Firs Name Last namer, f contractor,indicate type and license number <br /> Address O Pc(b /�� �] State ber � S2© <br /> Phone Phone Email `1�y1 <br /> 5 2 (� IA eras o it <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> I <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor , hitect <br /> D <br /> First Name Last name �Oor,in c et and icense number <br /> `'T 1 <br /> Address City rNT.,1',yOQH,NFCpV ZIP <br /> Phone Phone EmailE <br /> N <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly cha es associated with this project or activity will be billed to me or my business as identified on this <br /> form, <br /> I also certify that I have prepare t is lie tian n that wo o be performed will be done in accordance with all SAN lOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL aws <br /> APPLICANT'S SIGNATURE: DATE: <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <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 /> Accepted By Te4 C. Assigned To r a 1 Linked -AID T—A <br /> Date�r r _ PE I (0o� Fee y 1-71 Record Number R tC1 4 5 <br /> 1 `+i', Payment <br /> ❑Cash ❑Check#t Confirmation# Received By <br /> Rev 07/10/2024 1 O S��- l <br />