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tSl New Facility Existing Facility San Joaquin County Environmental Health Department 75 6/)ZIP 1^ APN Consultation Change of Owner Repairs or Remodel Other Billing Party Facility Owner Facility Contact Property Owner Contractor Architect Billing Party ^Facility Owner Property Owner Contractor Facility Contact Architect If contractor, indicate type and license number State ZIPCA Phone Ei Billing Party Facility Owner Property Owner Contractor Architect If contractor, indicate type and license numberFirst Name Last name Address City State ZIP Phone Phone Email Property Owner Contractor Architect Billing Party Facility Owner Facility Contact If contractor, indicate type and license numberFirst Name Last name ZIPStateCityAddress EmailPhonePhone Title Linked FA IDAccepted By Fee1^/ Check II Cash Rev 07/10/2024 PAYMENT RECEIVED If mobile food truck or pumper truck Contact Types required Application for Operating Permit Type of Service Requested Comments P PE Application Form DBA: If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMlN > aL hEaLI ZUtJ DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.__________________________SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Record Number APgSG) 2.1(4_____ Payment Received By ............ gp 6 W PJ Supervisor District Assigned To .Kaoecdw El Confirmation # 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. Z' I also certify that I have prepared this apoHcation and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, □ property Business owNErt^ □ operator/manager □ other authorized agent /YlonYQg SI ^/^o^ Facility Contact OPERATOR/MANAGER