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❑ New Facility 4/1-xisting Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> C1-1Ri�� OF 1N�Q1R CVIS, 11E <br /> Site Address City state Zip <br /> P��1vrlC. NNJE SITE [3 l S'COG TaN �� q�2Q <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation hange of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> C �� �� p <br /> If mobile food truck or License late Num r VIN pumper truck I C 1i <br /> V <br /> o'itact Types El Billing Party ❑Facility Owner Cl Facility Contact El Property Owner ❑.Contractor 1�/-T t <br /> requErecl !/ fJ <br /> a Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor <br /> H Tay � MEN��Nn, <br /> First Name Last name If contractor,indicate type and licens�i �N7, <br /> vv'mc Ic P <br /> Address Cit State ZIP <br /> Phone Phone Email Y'QC vNw.+'E <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First NameG Last name if contractor,indicate type and license number <br /> L 1 <br /> Address City State ZIP <br /> Phone t, Phone Email <br /> 'kI u SS <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name f�>\-\`f�C�t r Last name �;�� If contractor,indicate type and license number <br /> V <br /> Address ` <br /> 1 . City State ZIP 1 5 <br /> o aCA SMIT�� C��- I - <br /> P one 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 ap licatio nd that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and E <br /> APPLICANT'S SIGNATURE: ws <br /> DATE:r <br /> ❑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 <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. J <br /> Accepte0y ssignedJT� �a Linked FA ID <br /> a <br /> Date PE Fee Record Number 2 5 �y <br /> IL l Cl 5 Payment <br /> ❑Cash ❑Check a Confirmation M .2-1 7b 7 1;L� Received By <br /> Rev 07/10/2024 �� 0�[n rl�] � <br />