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New Facility <br />Application Form ?(LO\Jo\OtO <br />Facility Name <br />h I <br />Sui <br /> Consultation SZfhange of Owner Repairs or Remodel Other <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br /> Billing Party Facility Owner Facility Contact 'Q'Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />Phone <br /> Billing Party Facility Owner Efproperty Owner Contractor Architect <br />If contractor, indicate type and license number <br /> Facility Contact Property Owner Billing Party Facility Owner Contractor <br />Last nameFirst Name <br />CityAddress State ZIP <br />Phone EmailPhone <br /> OPERATOR / MANAGER OTHER AUTHORIZED AGENT PROPERTY / BUSINESS 'NER <br />Title <br />Assigned To <br />Fee <br /> Cash Check# <br />^*07/10/2024 <br />If APPUCANT 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 />First Name <br />Contact Types <br />required <br />Type of Service <br />Requested <br />Comments <br />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <br />ZIPState <br />Last name <br />Winn <br />ZIP <br />35713 <br />State <br />□^Existing Facility <br />San Joaquin County Environmental Health Department <br />Email C . , <br /> Facility Contact <br />Site Address <br />APN <br />Firsjjlame <br />oohn_________________ <br />Address a I . <br />Z> L? <7 0 C4v3 u pii b /I A <br />Phone ' JI Phone ’ Em. <br />Date \~l 25 <br />State ZIB <br />Linked FA ID <br />FAonOQ2'2? <br />Record Number <br />SR.2.501202__ <br />Payment <br />Received <br />Email <br /> Architect <br />If contractor, Indicate type and license pumt A**i <br />fTECFlVj <br />JUN <br />Accepted By <br />IT <br />D <br />^-2^5 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identifledcm tnrc^TM -J^T" <br />form. <br />I also certify that I have prepared thinoplicatlon 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. ) / . . / /------- <br />APPLICANTS SIGNATUrt^-^C^^/z^ DATE: G^/ }'Ji <br />Last name <br />on <br />5A <br />Phone ’-'I Phone L