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❑ New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name P� CIS $ W)n Lis <br /> te;llddress rCd s� City I L Stater ZI�, cv� <br /> :-- `U [ li <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate `Nm of VISI` <br /> pumper truck V K -61-4 1�—1 T1�9 X l (Q 0 M M `�l p /--I <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party Facility Owner Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First a Last na a If contractor,indicate type and license number <br /> - I��.��vf c� D��I�te�lU <br /> Ad¢resst✓, A, Fn 1 y e- City &Q' StatQ ZIP ��?2 <br /> Phone l ' NV UI IJYrPhorne all , J <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 Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor �t� <br /> c T <br /> First Name Last name If contractor,indicate type 76firwL'lil"ft <br /> r <br /> Address City State IP ��25 <br /> SAN J <br /> Phone Phone Email kN N�ALT EpMISNTA. <br /> IvIltNT <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 application and that the work to be performed i be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERA )� <br /> APPLICANT'S SIGNATU#E: las, DATE; 4 '7^ <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER 0-OTHER AUTHORIZED AGENT <br /> 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 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 /> Accepted By Assigned To Linked FA ID <br /> teff C. �r�t\CiS� �A mco2� I�� <br /> Date�1 1�5 P` �3 Fe1 +2.(2)O Record Number <br /> SQ25V 01-3 <br /> 4 Payment <br /> ❑Cash ❑Check# 4Confirmation# � O �� Received By <br /> Rev 07/10/2024 (fin 094 A1150 <br /> T'0 <br />