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XNew Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> C C C Q�- 1 <br /> Site Address Ci State ZIP <br /> APN Supervisor Dist <br /> Type of Service ❑Application for Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments /U ew A `)rF Ice rre 1 <br /> If mobile food truck or Lic ns Plat Number l•► Cam+,+JI V N <br /> pumper truck O <br /> Contact Types ❑Siding Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party VZaciflty Owner acilAy Contact El Property Owner ❑Contractor Fl- <br /> Architect <br /> First Nam Last name U I If contractor,indicate type and license number <br /> Address` l ,^ L l Cl€ty state, ZIP 2 6 <br /> Phone Phone— Email <br /> _)P 7--G S I <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact 0 Property Owner ❑Contractor ❑Architect <br /> First Name Last name if contractor,indicate type and Ilan �� <br /> Address City State ZIP •••D"` V� <br /> NnIll <br /> Phone Phone Email <br /> <IVV�0 4 <br /> lq C <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner I--]ContractorAttj` N] ry <br /> A,grMaC <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone 7_ Email <br /> BILLING ACKNOWLEDGEMENT:I,the uSned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project <br /> specific ENVIRONMENTAL HEALTH DEPNT hourlycharges associated with this project or activity will be billed to me or my business as€dentified on this <br /> form, <br /> I also certify that I have prepared this a n and h he work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> D PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT <br /> Tide <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 /> Accet d B Assigned To Linked FA ID <br /> p <br /> YRF C K�c �thne L <br /> Date PE Fee Rec rd Number <br /> rj f z q 1��3 \� P 2 <br /> 17� .r C7by J�( fS�S <br /> Rev pE/17./202a ^�� L` r . <br />