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San Joaquin County Environmental Health Department <br /> Application Form <br /> _ Facility Name , <br /> t l C' i 7r <br /> Site Address City State ZIP <br /> APN Supervisor District <br /> i <br /> Type of Service ❑Application for 5KC44vtGio ©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 a /'' � ��� � ����j �W61O <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ®Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name ` T Last name,i If contractor,indicate type and license number <br /> Address / C city State ZIP <br /> Pone P_hone/� r Email <br /> ❑Billing Party gFacility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If comFgFter,indieate typ 6.aari license numbaT. <br /> Address City. State ZIP <br /> 1 <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type an SMANENT <br /> Address City State zip <br /> Phone Phone Email S's IJ - 2'' <br /> or Zan ID: <br /> ENVI <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge thatIMUTWOL4PAWWENT <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges 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 prepared this application and that the work to be performed will be done in accordance with all AN JOAQLIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL law�� <br /> APPLICANT'S SIGNATURE: DATE: <br /> i <br /> Er 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 Assigned To r Linked FA ID <br /> Date PE r, Fee Record Number <br /> e?' 21 \b33 � I G1 <br />