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New Facility Existing Facility San Joaquin County Environmental Health Department 5524a Consultation Change of Owner Repairs or Remodel Other VIN Billing Party Facility Owner Facility Contact Property Owner Contractor Architect Property Owner Contractor Architect Facility Contact Billing Party Facility Owner If contractor, indicate type and license number Zll Email Property Owner Contractor Architect Facility Contact Facility Owner If contractor, indicate type and license numberLast nameFirst Name ZIPCityStateAddress Phone EmailPhone Facility Contact Property Owner Facility Owner Billing Party numberLast nameFirst Name DEC Uz,2025StateCityAddress EmailPhonePhone APPLICANT'S SIGNATURE: DATE: OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER Title Linked FA IDjigned Toited ByAct PE 043 Confirmation # Check H Rev 07/10/2024 and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, 4 - - zy If mobile food truck or pumper truck Contact Types required 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 Payment Received By Type of Service Requested Comments SAN JOAQUIN COUNTY environmental HEALTH DEPARTMENT 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 preparejithis. Standards, STATE and FEDERA'lTavj^J First Name 7 Address, . Phone / ^^55545 License Plate Number ^i2 □ Contractor PAYMENT^ If contractor, a IVWFj __I O/ 5 a Wo 5/ Billing Party 533 I 557 Date / Cash Application Form APN ^upervisorDistrict