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□ Existing Facility San Joaquin County Environmental Health Department State 5 APN □ Change of Owner □ Repairs or Remodel □ Other□ Consultation □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect□ Billing Party □ Facility OwnerU Billing Party □ Contractor □ Architect□ Facility Contact □ Property Owner If contractor, indicate type and license numbertrsilame State ZIP □ Contractor □ Architect□ Billing Party □ Facility Owner □ Property Owner If contractor, indicate type and license number Address ione □ Architect□ Facility Contact □ Property Owner □ Contractor□ Billing Party If contractor, indicate type and license numberFirst Name Last name Address City State ZIP Phone Phone Email DATE: □ OPERATOR / MANAGER□ PROPERTY / BUSINESS OWNER Title Assigned To Linked PAID Fee □ Check # Rev 07/10/2024 If mobile food truck or pumper truck Contact Types required ZIP Type of Service Requested Comments syj b f / y. □ Confirmation fl -VrtLCK VIN Facility Name ----------------------------------------------------------(—‘ Site Address i/fn ’/i 9 c, pi 4/Z co?’'' □ Facility Owner TA I Ema jf / 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, StandardSjSTA^^nc^EDERAL laws.A/] / Z4 APPLICANT'S SIGNATURE: - [J Application for Operating Permit PCV^GK License Plate Number __________Application Form or h llfrlci PMgrl . (A/cJ/W g A________ Supervisor District p New Facility ^/MENT □ OTHER AUTHORIZED AGENT RECEIVED Da,e4-3-^5 ________ Payment i Received By ( / e [a/^Iku Sr Phone If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required ADD fl 9 QHQFi AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above sire ad^reLk^erwZwJthorize the release of any and all results, geotechnical data and/or environmental/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._________________________________________________ ENVIRONMENTAL HbA» 11 i .. . .PE I DO I