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❑ New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form P%Z o5z s�3� <br /> � o s <br /> Facility Name /�/ A <br /> Site Address /L// ,v` <br /> APN Supervisor District <br /> Type of Service ❑Application for jq Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments y� CC.�i VCR,�OY� �"lC n �C F <br /> KQ. - <br /> If mobile food truck or license Plate Number VIN <br /> pumper truck <br /> Contact types ❑Billing Party ❑Facility Owner ❑Facility Contact D Property Owner Cl Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facility Owner El Facility Contact ❑Property Owner ❑Contractor ----P❑Architect <br /> If contractor,Indicate type and license number <br /> Q "�76' <br /> Z — <br /> Phone <br /> �� 2 <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 0 Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor P'M'Nwr <br /> First Name Last name If contractor,indicate type Mgr <br /> Address City state Zif g <br /> 3qH 2025 <br /> Phone Phone Email E U! <br /> y����HOUM <br /> BILLING ACKNOWLEDGEMENT:i,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site 5M oject <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 prepare i application a work to be erformed will be done In accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> StandardT„STATE and FEOERA aw . MOW �f /+;j-�Z- <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 /> AUTHOR17ATION TO RELEASE INFORMATION:When applicable,I,the owner ar 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 SANJOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT as soon as it is available and at the same time Et is provided to me or my representative. <br /> Act ted By Assigned To Linked FA ID <br /> `Gc.V- FA Q)Cn 2.5 ci 3 <br /> Oat P Fee Record Number <br /> � L812s [c�mz 1��.�� S 51499 <br /> (} ��C7 Cash El Check# Confirmation q /t]�J►� - Payment <br /> By <br /> Rev 01/10/2024 <br />