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New Facility □ Existing Facility San Joaquin County Environmental Health Department Facility Name Site Address 355 APN □ Consultation □ Change of Owner □ Repairs or Remodel □ Other VIN ZAA P-aDug6^13 □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect ^/Billing Party □ Facility Contact □ Property Owner □ Contractor □ Architect If contractor, indicate type and license numberLast name Address Cit' Phone Email ^/Facility Owner □ Property Owner □ Contractor □ Architect□ Billing Party If contractor, indicate type and license numberLast nameFirst Name State □ Contractor □ Architect□ Facility Contact □ Property Owner□ Billing Party □ Facility Owner Last nameFirst Name City StateAddress EmailPhonePhone DATE: □ OPERATOR / MANAGER OTHER AUTHORIZED AGENT Linked FA IDAssigned ToAccepted By □ Confirmation It□ Check it Rev 07/10/2024 Contact Types required If mobile food truck or pumper truck If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative._______________________________________________ yJZApplication for Operating Permit Citv FOB I ZIP 75^7 VO ZIP I / Phone State License Plate Number f/lfFacility Owner Type of Service Requested Comments Application Form 'TACDlfMWO IVC/ ui lA fxyc Supervisor District AddreX Phone _____ BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same,'am&] specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or form. I also certify that I have prepared this application and that the wj Standards, STATE and FEDERAL ISTS. APPLICANT'S SIGNATURE: □ PROPERTY / BUSINESS OWNER \JidoJL Pedraza PE|(t>0( Franc Seo RuiZ. If contractor, indicate ^g^i^^nse number — ind/or project fjnpd on this )Uf$MVpdinance Codes, ^7 City CC>hn {z Facility Contact (o be performed will be done In accordance with all SAN JOAQUIN COU Ti le 50,2444 , Payment zn ! Received By/ DaVu-a5 W*hi First Name i ' Lws LA _____ Phone Xh-CH)&-345^-7