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^3 Existing Facility New Facility San Joaquin County Environmental Health Department Application Form Facility Name APN ^S^thange of Owner Repairs or Remodel Consultation VINLicense Plate Number 2025 Facility Owner Contractorp f opd ty Owner Architect Contractor Property Owner Facility Contact^iQiilling Party Facility Owner If contractor, indicate type and license number 4 Architect^'Facility Contact Property Owner Billing Party If contractor, indicate type and license number ZIP ^3^Address Phone 'math Architect Facility Owner Billing Party If contractor, indicate type and license numberLast nameFirst Name ZIPStateCityAddress EmailPhonePhone 1 DATE: OTHER AUTHORIZED AGENT OPERATOR / MANAGERiUSINESS OWI TOAk(Z)Z Check# Cash Rev 07/10/2024 If mobile food truck or pumper truck Application for Operating Permit Payment Received By BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this api Standards, STATE and FEDERAL laws. / APPLICANT'S SIGNATURE: __________S ition and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Og - ^PROPERTY Last name Q facility Owner J_________ Type of Service Requested Comments /Ifth $-f- ’Email erp Title Uy Phone Last name __________ Email w | Facility Contact State^^ Assigned To FeeDate , . 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 envlronmental/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._ City Linked PAID Record Number _____________ /confirmation # 'Z.(2>XQ>Zi'2-Ci V ■ ~ City Phone Phone Email 7T . 209- %44.fey3z W W ffrmd.&im- Contractor State , C-A First Name (SlUrAN 4g ^6 ,117 r..w.,c Phone Aojj Aon First Name Address City TrflCcj Facility Contact Property Owner Contractor sl,eAW a 44^ u Supervisor District j SEp o r By. , \ve_ PE 7IP 211534