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cr^ew Facility Existing Facility <br />Facility Name <br />Site Addr™ <br />APN <br /> ComulUtion ChAnge of Owner Repairs or Remodel Other <br />V1N <br />H'Facil.ty Owner 0^F acilitv Contact Architect ContrxtorBilling Party Property Owner <br /> Architect Contractor Facility Owner Facility Contact Property Owner Billing Party <br />If contractor, indicate type and liceme numberlast name <br />Address <br /> Contractor Architect Baring Party Property Owner Facility Owner <br />If contractor, indicate type and license numberFirst F*ame Last name <br />State IKCityAddress <br />EmailPhonePhone <br /> Contractor Architect Property Own er Facility Contact Faclity Owner Billing Party <br />Last nameFirst tame <br />ZIPCityStateAddress <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR / MANAGER <br />Title <br />linked FA IDAssigned ToAccepted By <br />Record NumberFee <br />6Z!Rev 06/12/2024 <br />i— <br />I <br />if mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />If APPLICANT is not the BILLING PARTY, proof of authoriration 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 contractor, indicate type and license number <br />ZIP <br />Aissk <br />State <br />CJl <br />(ZAppkation for <br />Operating Permit <br />liceme Plate Number " ‘ <br />Type of Service <br />Requested <br />Comments <br />State <br />.email <br /> Facility Contact <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorited agent of same, acknowledge that alt 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 idenbfied on this <br />form. <br />I also certify that I have prepared this application and that <br />Standards, STATE and FEDERAL laws// A <br />APPUCANTS SIGNATURE: <br />Q^ROPE RTY / BUSINESS OWNER <br />lication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />^53MXlz, RNonJieuo E.firT <br />Phon.-), Phone .Email <br />Keceived °cr 02 <br />San Joaquin County Environmental Health Department <br /> Application Form <br />101oV.icc.ce._GVc <br />Supervisor District <br />WJO. ^5