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New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Mame <br />Site Address City <br />75 >0/ <br />ZIP <br />APN <br /> Consultation Repairs or Remodel Other <br />r <br />license Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />Ej Billing Parly [^Facility Owner Q'Facillty Contact Property Owner Contractor Architect <br />First Name |*Last If contractor, indicate type and license number <br />Address 'ZIP fS~2./ oC4 <br /> Billing Party Facility Owner Facility Contact Property Owner Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br /> Facility Owner Facility Contact Property Owner Contractor Billing Party <br />berFirst Name Last name <br />City StateAddress <br />EmailPhonePhone <br />OS / 2- 2- /DATE: <br /> OTHER AUTHORIZED AGENT <br />Title <br />Accepted By Assigned ToSB <br />FeePEM2 <br /> Check # Cash <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br /> Application for <br />Operating Permit <br />Payment <br />Received By <br />;oject <br />In this <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 />Pot <br />Tftcf-fCC AvC <br />Supervisor District <br />Type of Service <br />Requested <br />Comments <br />Phone <br />__________ <br />LB <br />JH-za liH1- <br />^Confirmation ti <br />Phone <br />Date <br />0 Change of Owner <br />(/(gp L- ccrrvfl <br /> Contractor <br />I Architect <br />payment <br />If contractor, indicatOlJ«cUU^ise rttimb <br />Linked FA ID , x-j <br />reCOrdNUSk^5011P^ <br />2025 <br />_^9.Qonty <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identifiecTdn <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 />StanM^!W^.n-d r.EDERAL laws. , <br />APPLICANT'S SIGNATURE: ^4-/Tuflfl r <br /> PROPERTY / BUSINESS OWNER OPERATOR / MANAGER