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[X Existing Facility New Facility San Joaquin County Environmental Health Department APN Exchange of Owner Consultation Repairs or Remodel Other License Plate Number VIN Billing Party Facility Owner Facility Contact Property Owner Contractor Architect ^Billing Party ^Facility Owner Facility Contact Property Owner Contractor Architect First Name Phone Billing Party Facility Owner Facility Contact Contractor Architect First Name If contractor, indicate type and license numberLast name Address City State ZIP Phone Phone Email Billing Party Facility Owner Facility Contact Property Owner Contractor let ;e numberFirst Name Last name Address City Phone Phone Email OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER Title Cash Check « Rev 07/10/2024 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. If mobile food truck or pumper truck Application for Operating Permit If contractor, indicate type and license number State Type of Service Requested Comments Application Form Supervisor District ______________________________________________________________________ - 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. y // .(J - — I ; I I <7 ^7" APPLICANT'S SIGNATURE: ' ' ' '■ A ____________________ DATE: J / / / ' OPEROTOR/ MANAGER RHcSS If contractor, indicate type and1 _____JUL J /State ' ' S4^J0A0i|in Addrcss | Phone Assigned To L-U^dlC^ Accepted By JeV? Q Date . Last name t ,y Kmv Ti-fr-ry 1 Email ' . . \)0Ud’J/\&kM> a) ya 1/100 Property Owner \tnU ch pe^2- Linked FA ID •_________________FAOQXZ) l'2_G?S Record Number_______I ^Confirmation# \ (j> |Payment l\ Received By '—