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4ew Facility C] Existing Facility <br /> San Joaquin County Environmental Health Department <br /> _ Application Form <br /> -e r-e,-, CA et P� --�- �Ccol <br /> Gi[y— <br /> 4`1 VA i D 1 2-0 <br /> APN Supervisor District <br /> Type of Service pplicatlon for I❑Consultation Cl Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested -1"rating Permit <br /> Comments 1a ,A � ,f1 <br /> if mobile food truck or License plate Number VIN <br /> pumper trunk <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required a �� <br /> Cl Billing Party ❑Facility Owner ❑Facility Contact D Property Owner ❑Contractor ❑Architect <br /> First Ndl Last name if contractor,indicate type and license number <br /> Tyth Lj pe <br /> �ddress <br /> Phon Phone rA <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact Q 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 ❑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 ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTIQ �odes, <br /> Standards,STATE and FEDERAL lay s nL- <br /> r `2 F-0E� <br /> Y CEIVE <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title OCT 0 9 2025 <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site act i�i}�alutLrize the <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIR hof� �UH <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. NMENT <br /> Accepted By r Assigned To �Q Linked FA ID <br /> Date PE Fee L Record N amber <br /> 2� � Payment <br /> E:Cash ❑Check 33 Confirmation tf Received By <br /> Rev 07/10/2024 <br />