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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name }} <br /> Site Address ff-a City �1 State ZIP <br /> /1/ <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation 0 Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plat um er // VIN <br /> pumper truck/11+ C'J S <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> 11 Billing Party Facility Owner ❑Facility Contact D Property Owner ❑Contractor ❑Architect <br /> First Name L Z Last name If contractor,indicate type and license number <br /> Address ZIP <br /> kk)oA ( r �G St4tR' C 2 <br /> Ph a Phone Small <br /> 0 <br /> L]Billing Party ❑Facility Owner Er Facility Contact ❑Property Owner ❑contractor -F❑Architect <br /> First Nam / Last name J If contractor,indicate type and license number <br /> Addressj C>irr 0C <br /> Phon Phone Email -1 / 5tate� p �,•��o <br /> e L f ( C� <br /> Zc�l�2©-a�17 <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 City State ZIP <br /> Phone Phone Email <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br /> form. <br /> I also certify that I have prepared this tic Fnt a he work to be performed will be done in accordancewi all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,57ATE and FEDERAL laws.APPLICANT'S SIGNATURE: DATE: I <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT A Title �� <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 <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONM£-"L HEA <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. �y <br /> zt <br /> Accepted By Assigned To Linked FA ID G <br /> 513 CM <br /> Date PE Fee Record Number <br /> f- 13-a5 r t� o � � I �] � �a: <br /> ❑Cash ❑Che ck# Payment <br /> U3 Confirmation k G `T' Received By <br /> Rev 07I10l2024 <br />