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<r[^Existing Facility New Facility <br />Facility Name <br />grfe&nl State caAPN <br /> Consultation Repairs or Remodel OtherChange of Owner <br />License Plate Number VIN <br /> Billing Party Property Owner Facility Owner Facility Contact Contractor Architect <br /> Facility Contact Property Owner Contractor Architect <br />First Name If contractor, indicate type and license numberLast name <br />i i State <br />Zl <br />Email <br /> Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />EmailPhonePhone <br /> Property Owner Contractor Architect Billing Party Facility Owner Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />City State ZIPAddress <br />Phone EmailPhone <br />Title <br />Linked FA IDAssigned ToAccepted By <br />Record NumberFee <br /> Confirmation W Check « <br />Rev 07/10/2024 ^2500^0 <br />1 <br />If mobile food truck or <br />pumper truck <br />San Joaquin County Environmental Health Department <br />AFzscozi'At <br /> Application for <br />Operating Permit <br />ZIP <br />95 2J? <br />Contact Types <br />required <br />sfailling Party <br />Type of Service <br />Requested <br />Comments <br />ZIP <br />^Facility Owner <br />V? <br />PE <br />O <br />orh i<7 <br />Phone Email <br />Address -mu <br />Phone <br /> Billing Party <br />hric/rgdc__ <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 tTi? <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.gz ., ' <br />5R2400505 / <br />Payment . p / <br />Received By <br />_________Application Form <br />El mhCiense <br />Supervisor District <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 />form. <br />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, <br />Standards, STATE and FEDERAL laws. K? . I \ / / O ! Z./ <br />APPLICANT'S SIGNATURE: / j \ | O QI \ Q Zf /(] DATE: / ~" / (y Z. / <br />Q^PROPERTY / BUSINESS OWNER □ OPERATOR / MANAGER □ OTHER AUTHORIZED AGENT