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li. Existing Facility New Facility San Joaquin County Environmental Health Department Application Form Facility Name El Site Address ZIP APN ■^Change of Owner Consultation Repairs or Remodel Other Billing Party Facility Owner Facility Contact Property Owner Contractor Architect Facility ContactFacility Owner^.Billing Party Property Owner Contractor Architect If contractor, indicate type and license numberFirst Name Last name Address City State ZIP Contractor Architect Billing Party Facility Owner Facility Contact If contractor, indicate type and license numberFirst Name Last name ZIPAddressCityState EmailPhonePhone Contractor Property Owner Facility Owner Facility Contact Billing Party First Name Last name City StateAddress Phone EmailPhone nLuMiz.DATE: OTHER AUTHORIZED AGENT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER Title Cash Check H ^0^122.Rev 07/10/2024 Contact Types required If mobile food truck or pumper truck Application for Operating Permit Payment Received By 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, hereby authorize 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. Phone kfconfirmation it State f.A Type of Service Requested Comments Linked FA ID Record Number Avto A\/t Phone vfro___________ S C<%liforh|ck St Supervisor District City License Plate Number __________H K/ 5 Accepted By VicloJt Y. Date T\\5\Z5 /•Went If contractor, indicate 7 F 15 2025 __________________________________________________ BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site 5?rayM*ttaUEFl 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, Standards, STATE and FEDERAL laws.. 4 . ._ — APPLICANT'S SIGNATURE: 'h .M J _________________________ DATE: -) 1/1 y I h f 7-^ b VIN I K.S ()4 302-2. Email Rubin. I ____ Property Owner Assigned To ci i (X VD Fee ,