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[X New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Webers <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br /> Billing Party Facility Owner Property Owner Facility Contact Contractor Architect <br />^0 Billing Party JZ1 Facility Owner Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />ZIP <br />Phone <br /> Billing Party Facility Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor <br />First Name Last name <br />Address City State <br />Phone Phone Email <br />DATE: <br /> PROPERTY / BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br />Title <br />Linked FA IDAssigned To <br />Date <br />LU Cash Check II <br />Rev 07/10/2024 <br />Contact Types <br />required <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 />If mobile food truck or <br />pumper truck <br />Application for <br />Operating Permit <br />Payment <br />Received By <br />Meto LUR P-exneuD <br />License Plate Number <br />ion and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />State <br />Macs <br />Type of Service <br />Requested <br />Comments <br />Email <br /> Facility Contact <br />DopLXAWU <br />Site Address t <br />b. C(X\\\ct \0\ <br />Supervisor District <br />Accepted <br />Date _ <br />5-I5-95 <br />mvj_____________ <br /> Property Owner <br />O Facility Contact <br />------ <br />__________________________,_________„__________, ________________ _____ _ ___________„____ _____ ________r-wTr-B^ ^Hd/or project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business affiCA^ied on this <br />form. <br />I also certify that I have prepared this appjji <br />Standards, STATE and FEDERAL <br />APPLICANT'S SIGNATURE: <br />First Name <br />Address <br />Phone <br />I Architect <br />If contractor, indQtf<vjje anfll3jM?jTlbmber <br />— <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowl^c^fjf^i^l <br />State <br />vin_W <br />Fee. _PE Record Number <br />_________ 7\pa50 20 4<8 <br />I Confirmation « 3? <br />aP <br />Last name