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❑ New Facility l X Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name r <br /> o v 65 <br /> Site Address CityG�fi State (� ZIP�I <br /> y 1 [ 11Cfv�— 5 <br /> 7- <br /> APN Supervisor Disthct <br /> Type of Service 9 Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> ?V\.P—.1 o �s( ��.� <<�tr.� ► �o� CCIL iti. S CJS <br /> If mobile food truck or License Plate Number / VIN ! / q <br /> pumper truck zAvA1�ro 1\J. IV Jn .11 <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner 11Contractor ❑Architect <br /> required <br /> 51 Billing Party C3 Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name . Last name If contractor,indicate type and license number <br /> Address1 1 :1 City State �� ZIP11 <br /> WV4 <br /> Phone Phone Email <br /> MA (jb'VA- <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact 7operty 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 ❑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 application and that th rk to erforme a done in DATEaccordan�cee with all SAN <br /> 'JJOAQ�UIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. 0 % Y��I�J PA <br /> APPLICANT'S SIGNATURE: : <br /> [9"PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required 4 <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site addreswe authoLrlte /C <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRON � NT H_veJ <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> Accept e Assigned To f Z_ Linked FA ID MFNT <br /> ( vIe-SC o LsZ F-6000&452 <br /> Date PERecord Number <br /> (KIW?—.5 F e i(003 1-42SRS?'5(2)Iml l <br /> ( <br /> 2 <br /> ❑Cash ❑Check# L`7 Confirmation# Payment <br /> 15233 Received By <br /> Rev 07/10/2024 X 05 0 <br /> I'4q <br />