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□ New Facility □ Existing Facility San Joaquin County Environmental Health Den .rtment 54 APN 53'Change of Owner□ Consultation □ Repairs or Remodel □ Other License Plate Number VIN □ Architect□ Property Owner □ Contractor□ Facility Owner □ Facility Contact□ Billing Party □ Architect□ Contractor□ Facility Contact □ Property OwnerQ Facility Owner□ Billing Party If contractor, indicate type and license number tman □ Architect□ Property Owner□ Facility Contact□ Facility Owner If contractor, indicate type and license numberLast nameFirst Name ZIPCityStateAddress EmailPhonePhone □ Architect□ Contractor□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party If contractor, indicate type and license numberLast nameFirst Name ZIPStateCityAddress EmailPhonePhone DATE: □ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGER® PROPERTY / BUSINE!'NER Linked FA IDAccepted By Record Numb<FeePE m □ Checks Rev 07/10/2024 f mobile food truck or pumper truck Contact Types required •■^Application for Operating Permit Payment Received By k ■ Vc Mfr ZIPState cA ZIP <^^3 3 State CA Type of Service Requested Comments □ Contractor last name Title Application Form \ If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required 18 2025 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 F^M^AQNUIN^I^UNTYj DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. ENVIRONMENTAL I (A Y k C A/ t Z\ Supervisor District /J Io Site Address /OZb [^Confirmation II yy I Phone I tmai I | 7j7l<yvV\ lAf X K c 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 appljezition and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. 4/ -/ u 1 PAYMFMT APPLICANT’S SIGNATURE: -----DATE: 1 2----------------’ RECEIVED Date | i □ Cash Facility N, YV\ V S' __ City . ________< CC4 Address _____ i ,Phone II □ Billing Party