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I ^Existing Facility□ New Facility San Joaquin County Environmental Health Department Facility Name Site Address APN □ Consultation □ Change of Owner □ Repairs or Remodel □ Other □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect □ Facility Owner □ Contractor □ Architect If contractor, indicate type and license numbery Email □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect First Name If contractor, indicate type and license numberLast name Address City State ZIP Phone Phone Email □ Billing Party □ Facility Owner □ Facility Contact □ Contractor□ Property Owner □ Architect First Name If contractor, indicate type and license numberLast name Address City State ZIP Phone Phone Email JUL 2 1 2025 I□ OTHER AUTHORIZED AGENT□ PROPERTY / BUSINESS OWNER □ OPERATOR/MANAGER Title Accepted By Di □ Cash Rev 07/10/2024 □ Property Owner i Contact Types required □ Application for Operating Permit State - Cx&fomici ZIP - -City Stockton ^^Confirmation « Type of Service Requested Comments VIN ___________Application Form Taco 5xx press LlC- - ibwrr<x Supervisor District License Plate Number brottwcs LLC. .State pEfBilling Party First Name AVoef-Vc___________ Address po e>ox PhoneI Phone If mobile food truck or License Plate I pumper truck IMPIP □ Check tl .State _ ZIP '^Facility Contact Last name ' Itoecroc GyofroT..______ City 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 I also certify that I have prepared this application and that the work to be performed will be dope injfcordance with all SAN JOAQUIN CO! APPLICANT'S SIGNATURE: _______ /fc/ber-fo /fcuTs- Qo.v-d z- Voatc: JbVu 202.6 RECEIVED UntedFA'W&t)W,?. I If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required SAN JOAQUIN COUNTY AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site addregHVIRONNlENTAL release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENDEPARTMENT DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative W