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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form I I-,2(-3oncp <br /> Facility Name <br /> SiteAddress e S City State ZIP <br /> APN Supervisor District <br /> Type of Service Xlpplicauon for ❑Consultation ❑Change of owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permft <br /> Comments <br /> If mobile food truck or License Plate NumberVIN <br /> pumperA f truck y3 9 4 /t aG 1? O/9676 <br /> Contact Types Billing Party 214cility Owner Wacility Contact /�❑� Property Owner ❑Contractor 0 Architect <br /> required <br /> 0 Billing Party acility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name � Last name If contractor,indicate type and license number <br /> 1� �n o�aSQ <br /> Address✓�A 'W( S �2 City <br /> er4m��rU State ZIPS <br /> Phone `J "( Phone Email i !� <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 Clty State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and Isce er <br /> Address City State ZIP I 11 <br /> I�ii <br /> Phone Phone Email V <br /> qN in 20 <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge th as i eh� <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business <br /> form. rMElvr <br /> I also certify that I have prepared t 's application and that the work to be performed will be done in accordance with ail SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERA law <br /> APPLICANTS SIGNATURE: DATE: O q I-2-3�t. <br /> Z PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <br /> If APPLICANT is not the B1LLtNG 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 ,r Assigned T Tie— Linked FA ID <br /> Date PE Fee Record Number <br /> ❑Cash ❑Check# Confirmation# 1971.3 <br /> P 71 2- 77 Payment <br /> (�c� f [ Received By <br /> Rev 07/10/2024 <br />