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□ New Facility □ Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name Site Address APN □ Consultation □ Change of Owner □ Repairs or Remodel □ Other VIN □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect □ Property Owner □ Contractor □ Architect If contractor, indicate type and license number □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect If contractor, indicate type and license numberFirst Name Last name ZIPCityStateAddress Phone Phone Email □ Contractor□ Property Owner□ Billing Party □ Facility Owner □ Facility Contact Last nameFirst Name StateAddressCity EmailPhonePhone □ OTHER AUTHORIZED AGENT Title Assigned To Fee □ Check#□ Cash Rev 07/10/2024 Contact Types required □ Application for Operating Permit Payment Received By ZIP ^52 J Z Date \\.\<V2-S □ OPER; License Plate Number HUGqi 3 7 State^^ ^Confirmation « Type of Service Requested Comments TJ Inc , fin S Supervisor District Linked.FAID _____rnooo22SO ^17^^- RCCtCh yeti cm fe/Zwi 11 If mobile food truck or pumper truck and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, __________date- inriov. RATOR/MANAGER 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. Pangs n State CH Accepted By PE □ Facility Contact Last name/ ZIF5 City StocMgn □ Facility Owner VtKP Hi G. Si njfyy □ Billing Party First Name v Address3^q Seger Phone Phdne Email □ Billing Party —----------PeP If contractor, indicate type aqAyyepse number 9 I ____________________________________________________ r^r- 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 prepared this applicath Standards, STATE and FEDERAL lajvs/ ; APPLICANT'S SIGNATURE: \< gfpROPERTY / BUSINESS OWNER