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❑ New Facility 0 Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address City State ZIP <br /> ( <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation l Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> ff <br /> If mobile food truck or License late Number VIN <br /> pumper truck Lf t y I-) j tZ` z E q^16114 <br /> Contact Types ❑Billing Party I ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required 11 <br /> Billing Party Facility Owner Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City state ZIP <br /> l I Z i ct f]2 ZQ <br /> Phone Phone Email <br /> 71 <br /> ❑Billing Party ❑facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact 0 Property Owner ❑Contractoryt@4t <br /> First Name Last name If contractor,indicate ty ■J ber <br /> Address City State zt ?425 <br /> J <br /> Phone Phone Email <br /> f1F�T RO EN UIy]y <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all sit&-affiWr 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 /> form. <br /> I also certify that I have prepared this applicatio nd at a work to be performed will be done in accordance with all SAN JOAQ IN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDE laws. I/ I <br /> APPLICANT'S SIGNATURE: DATE: <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT <br /> Title <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 ail 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 /> Accepted By signedT1 Linked FA ID <br /> FRmm2--�-:�m5 <br /> Date � 12-1 <br /> P£ Lck# <br /> Fee Rord Number <br /> // Payment <br /> ❑Cash ❑Ch Confirmation# 2-0b U �71 Received By <br /> Rev 07/10/2024 Wm <br />