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O' Existing Facility□ New Facility San Joaquin County Environmental Health Department Facility Name I Site Address APN □ Other□ Repairs or Remodel□ Consultation VINLicense Plate Number □ Architect□ Contractor□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party JiPacihty Owner □ Architect□ Contractoricility Contactling Party If contractor, indicate type and license number Address □ Architect□ Property Owner□ Facility Contact□ Billing Party If contractor, indicate type and license numberLast nameFirst Name ZIPStateCityAddress EmailPhonePhone □ Contractor□ Property Owner□ Facility Contact□ Billing Party □ Facility Owner Last nameFirst Name StateCityAddress EmailPhonePhone lat the101 DATE: □ OPERATOR/MANAGER □iPERTY / BUSINI IER AUTHORIZED AGENT 'OWNER Accepted By Assigned To Linked FA ID □ Cash Rev 07/10/2024 L mcVicx B □ Confirmation H TJefC C. PE If mobile food truck or pumper truck 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. □ Application for Operating Permit Date 3-4 .3 O 7^/ □ Cc/ntractor Type of Service Requested Comments Application Form >r District □ Property Owner Phone _______ □ Facility Owner Record Number Payment , i Received By f Fee J □ Check^^ ^1 ______________________________ -- ____ BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge thars^AeYw/of^roject specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as larfycrtied on this I also certify that I have prepared this appjjcatlonlaPctlFat thevyerJCKJ^performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAt4aws._^d^^7Z-----//‘ f / Q "P--------------------------------------------------------------------------------------------------- APPLICANT'S SIGNATURE: DATE 1 J / ^-{/C*. j Title □ Architect If contractor, indicate typ^^d^^ft^umber