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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Skin & Shades Studio <br /> Site Address City State ZIP <br /> 37 W. Yokuts Ave, STE B, Studio 21 Stockton CA 95207 <br /> APN Supervisor DistrictD <br /> 10220077 <br /> Type of Service KI Application for )IQ 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 /> pumpertruck <br /> Contact Types )(]Billing Parry )10 Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> V Billing Party $I Facility Owner IX Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Jennie Last name Rodriguez If contractor,indicate type and license number <br /> Address City State CA <br /> 436 Cowell Ave Manteca <br /> Pho 3- a Phone Email <br /> 0 <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 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 will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. RE YM <br /> APPLICANT'S SIGNATURE: DATE: } <br /> PROPERTY/SU51NESS OWNE OPERATOR ANAGER ❑OTHER AUTHORIZED AGENT ci DI <br /> if APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title NOIi Q <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hellyy 1' i 1 the <br /> release4 <br /> release of any and all results,geotechnical data and/or environmental/site assessment Information to the SAN JOAQUIN COUNTY ENVIRONMEN uCh41''N CO <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. f'1F,a, "' Afejv N� <br /> AL <br /> TM NT <br /> Accepted By / n ,r.m j Assigne <br /> ad To 5 Iy1 eio^IleL Unked FA ID <br /> Date 11 1 q 101'4 PE Fee V I� Z I D �f R dr N �D 11/9p Zq <br /> la: �a�d - cc# .Igtc�lo�t� Il 1� �2q- <br />