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—-i i '"■miWMri*—— <br /> ■V- . ..wft Ulb J—4..?" <br />[^Existing Facility <br /> New Facility <br />uar-— <br />FaciMtv Name <br />ZIP,12^citx. <br />CxC <br /> Other Repairs or Remodel Consultation <br />License Plate Numberor <br /> Architect Contractor Property Owner Facility Owner Billing Party <br /> Architect Contractor Property Owner <br />If contractor, indicate type and license number <br />Last name <br />Address <br />Phone <br /> Architect Contractor Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPStateCityAddress <br />EmailPhonePhone <br />■chi Contractor Property Owner Facility Contact Facility Owner Billing Party <br />Last nameFirst Name <br />StateCityAddress <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT <br />Title <br />Fee <br /> Cash Check ti <br />Rev 07/10/2024 <br /> <br />5 <br />™ • J <br />.. .11 B— ===== <br />Contact Types <br />required <br />If mobile food truck <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 authorue 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 />Type of Setv.ce <br />Requested <br />Comments <br /> Appfication for <br />Operating Permit <br /> I <br />ss(FacilitY Owner ^Facility Contact <br />^Change of Owner <br />Email <br /> Facility Contact L <br />Calling Party <br />First Name <br />,u fl) QP-Voj COCry <br /> Property Owner <br />s“'&, <br />APN <br />If contractor, indicate type and license number <br />0? 2025 <br />s <br />Date <br />\o-~V 2-5 <br />Accepted ^y <br />PE <br />Assigned To <br />• W <br />San Joaquin County Environmental Health <br />AppIication Form ____ <br />I VIN <br />V577 _ <br />Linked FA ID <br /> Confirmation U 20)5 O ^>\ | Received By <br />■Pjqcxoq c A/u\r;t;on_ <br />Supervisor District <br />1 Facility Contact <br />City__ <br />inxi <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 />l7lso 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 />Property / business owner Operator / manager <br />CHcx________ <br />7^6^ filWk CA <br />____ | Phortv <br />ao'i-Sis-yto* I _______