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2 New Facility ❑ Existing Facility <br /> t <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address ` l , I b\V City State <br /> APN W Supervisor District <br /> Type of Service pplication for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types filling Party acility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> Fir me s Last a If contractor,indicate type and license number <br /> Address city State ZIP C�'-7 <br /> ` <br /> 6-7 <br /> on Phone Email <br /> 3 k i/A <br /> ❑Billing Party Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name /y Last name If contractor,indicate type and license number <br /> GM <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 prepare this application and[hat the work to be performed will be done in accordance with all SAN JOAQ N COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL r <br /> APPLICANT'S SIGNATURE: DATE: <br /> ROPERTY I BVSINESSO ❑OPERATOR/MANAGER ❑OTHER AUTHORIZEDAGENT <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 /> lo <br /> Date PE Fee Record Number <br /> ;517/42 n 4❑Cash ❑Check# onfirmation# Payment <br /> Received By <br /> Rev 07/10/2024 <br />