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^B^Existing Facility <br />Facility Name <br />State <br />GA <br />jHj:hang<? of Owner □ Other□ Repairs or Remodel□ Consultation <br />VIN Ha <br />□ Archft ect□ Contractor□ Property OwnerFacility Contact□ Facility OwnerBilling Party <br />State <br />Phone <br />□ Architect□ Contractor□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPStateCityAddress <br />EmailPhonePhone <br />□ Contractor□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party <br />Last nameFirst Name <br />StateCityAddress <br />EmailPhonePhone <br />ienormiie worl <br />DATE: <br />□ OTHER AUTHORIZED AGENT □ OPERATOR / MANAGER <br />I Hie <br />Rev 07/10/2024 <br />I If mobile food truck or <br />□ Application for <br />Operating Permit <br />^^ROPERTY / BUSINESS OWNER <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 />San Joaquin County Environmental Health Department <br />Application Form <br />City ZIP <br />AH <br />If contractor, indicate type and license number <br />________,__________________ <br />ZIP <br />qs'Z-OM <br />Type of Service <br />Requested <br />Comments <br />1 f - frUAAjl A- <br />License Plate Number <br /> <br />/Amc - <br />Supervisor District <br />Email <br />If contractor, indicate type antfl <br />0$u 2°25 <br />,_____________________________________ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or <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 />I also certify that I have prepared this application a ndJbarnTewodpL^bTTTr^ or mechyill be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. I S ! 'Z. <br />APPLICANT'S SIGNATURE: ___________GrT—---- DATE: ---^.Z ---------- <br />... ■WtfWfrSrja <br />SZZIISWb 0r0.8<oZ5S <br />U New Facility <br />Site Address <br />23QO <br />APN <br />City <br />c GAo <br />—First Name A k c—e r<X— AAz>\< <br />pCXOCK <br />Address r—4 <br />iOOO . <br />Phone <br />720 HSO : <bZ3 <br />V, - w-;. <br />££7^ <br />______f WrVif’ <br />.......'—J .ruck or License <br />pumper truck