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v\ U □ New Facility □ Existing Facility San Joaquin County Environmental Health Department State ZIP ^53-7^ APN Js^Xhange of Owner □ Repairs or Remodel □ Other□ Consultation License Plate Number VIN □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect □ Facility Owner □ Property Owner □ Contractor □ Architect -A<ti \ If contractor, indicate type and license numberFirst Name Last name StateAddress □ Facility Owner □ Property Owner □ Contractor □ Architect If contractor, indicate type and license number State Phone □ Contractor□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner First Name Last name Address City State Phone EmailPhone TV \\i DATE: □ OTHER AUTHORIZED AGENT □ PROPERTY / BUSINESS OWNER □ OPERATOR/MANAGER Title Accepted By Assigned To PE Fee □ Cash □ Check U Rev 07/10/2024 If mobile food truck or pumper truck If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. □ Application for Operating Permit Phone ZIP 5 3 Z Phone 123% ^^illing Party J^acility Contact poe^ City ' ' Type of Service Requested Comments Sal Ito peppeiQ r(a)f (nVl^-rprv □ Facility Contact 4 2-0 KaS Phone Hl______ frm— Ml?- Confirmation ti I Irsi r. Contact Types required PA- Email 4/2-4 / 2-5 Application Form Site Address . 5-7 il^4k : Supervisor District Z!P Last name Address 1 > t Email FirstNOT16 / —-T- Tim 'Hrocc □ Architect If contractor, indicate tyt .number _________________________________________________________________________ BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge tn^P^lHitW^d/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as i^lSh^wd on this form. 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, Standards, STATE and FEDERAL laws. A I APPLICANT'S SIGNATURE: _________ ) .) I'' ) I fl Linked FAJD TA 0003 1^_______ Record Number Payment (T JL Received By