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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name , <br /> 21,54 S �1 1Do�clo S� Sa ocKk�, �t <br /> Site Address _ City State ZIP <br /> 2kS;4 5 L( 0C) c4d0 S CA (7Lc <br /> APN Supervisor District <br /> 167-M-210-Ow <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments �y� n I ' y�/� + <br /> m tJ tltZv {✓tl� �1j CJI' rF-h S��f 11 G7'hb'� �� 1 \VJ-1L4 Gnd I YN Ud -IS- <br /> If mobile food truck or License Plate Number r <br /> IN <br /> pumpertruck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <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 /> 1 l zq\ Fyrl�-e,s VJ 60ia R: CA <br /> Phone Phone Email <br /> 614� I3'51 0( cl �<C-J-N Coey <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 /> farm. <br /> I also certify that I have prepared this applicat nand that the work to be performed will be done in accordance with II SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. 1 •L,5 <br /> APPLICANT'S SIGNATURE: "� DATE: 3 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER OTHER AUTHORIZED AGENT A'0'LK <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 Q Linked FA In <br /> D �Zcord Number <br /> ��Z ! PE Z y Fee?C r �� ReSP-2-50\335j <br /> (� } b <br /> ❑Cash ❑ eck# ❑Confirmation# PaymentReceived By <br /> Rev 07/10/2024 <br />