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1 New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> r <br /> CA <br /> Ale h�� <br /> FAP Supervisor District <br /> Type of Service Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> Perrn-,iA \n Neer ced Co�,oAA <br /> If mobile food truck or <br /> pumper truck <br /> Contact Types ❑Billing Party ©Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> l�Billing Party Facility Owner CkFacility Contact ❑Property Owner ❑Contractor ❑Architect <br /> W7 1 If contractor,indicate type and license number <br /> ii i n' <br /> T- <br /> imm ��0 7-cie Ali <br /> Phone <br /> *�-�1 - <br /> 5 <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 ❑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 hcuriy 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 will be done in accordance w hall SA JOAQUIN COUNTY Ordinance Codes, <br /> Stand TAT ERAL is s. <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,geotechnica?data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HLACTH <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> Accepte v^�� C- C. Assigned To 1 -A c 4� � L{nked FA ID <br /> Y -�.S � L V vC.l.. <br /> Date PE Fee Record Number <br /> ElCash ❑Check 0 ❑Confirmation# Payment <br /> Received By <br /> Rev 07/10/2024 VP 25 Y {l 2 <br />