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□ Existing FacilityNew Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Site Address City State ZIP <br />5512kCA <br />APN <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />Billing Party □ Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license number <br />□ Billing Party □ Facility Owner □ Facility Contact □ Contractor □ Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address City State ZIP <br />Phone Phone Email <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner <br />First Name Last name <br />Address City <br />Phone Phone Email <br />DATE: <br />□ OTHER AUTHORIZED AGENT □ PROPERTY / BUSINESS OWNER □ OPERATOR/MANAGER <br />Title <br />Linked FA IDAccepted By Assigned To <br />UOI cc:□ Check #□ Cash <br />Rev 07/10/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <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 />□ Application for <br />Operating Permit <br />Payment <br />Received By <br />Date <br />Type of Service <br />Requested <br />Comments <br />ITeFP Carruesco <br />PE <br />B^Facility Owner <br />Last name <br />V)o(\GCxX\ <br />I Email <br />Q A c <br />Supervisor District <br />□ Property Owner <br />ZIPCity <br />Tra c <br />cr License Plate NumberH <acxq <br />fJecU Tru-Clc___________ <br />VIN <br />First Name-. <br />Address , . <br />Phone " Phone <br />2OQ-65O- 8102- <br />Record Number ________AP2502205 <br />^Confirmation tt <br />State . <br />V i d PeAr aza <br />Fee$5l(p <br />□ Contracto <br />If contractoi«/6^teate type a^^Ose number <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.^- , -----, x , - O PT <br />APPLICANT'S SIGNATURE: ~ ~ DATE: L4-D