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Existing Facility□ New Facility San Joaquin County Environmental Health Department >s APN □ Consultation Change of Owner □ 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 Last nameFirst Name If contractor, indicate type and license number(ril/CnvC Address Citi ite Cfi Emai □ Billing Party □ Property Owner □ Contractor □ Architect□ Facility Owner If contractor, indicate type and license numberFirst Name Last name ZIPAddressCityState Phone Phone Email □ Architect□ Property Owner □ Contractor□ Facility Contact□ Billing Party □ Facility Owner If contractor, indicate type and license numberLast nameFirst Name City State ZIPAddress EmailPhonePhone □ OTHER AUTHORIZED AGENT □ OPERATOR / MANAGER□ PROPERTY / BUSINESS OWNER Title c. □ Check II□ Cash Rev 07/10/2024 '______J Contact Types required If mobile food truck or pumper truck □ Application for Operating Permit 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 COUN FY Ordinance Codes, Standards, STATE and FEDERAL laws. . ... U Bk^onfirmation H | | PE .\UI)2 Application Form DEC. Type of Service Requested Comments Accepted By __3e££ Date 43^ Supervisor District □ Facility Contact | Facility Name h/AAUt_______ gtnz MW CT. Phone Assigned To Fee inz-ocp If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Wizty'7' AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereb^W^W^^ release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HLAI nr DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.Q Linked FA ID Record Number T SR.2-,D«XI)dcR Payment Received