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X X □ Consultation □ Change of Owner □ Repairs or Remodel □ Other License Plate Number VIN □ Facility Contact □ Contractor □ Architect□ Billing Party □ Facility Owner □ Property Owner Billing Party ^3 Facility Owner □ Property Owner □ Contractor □ Architect□ Facility Contact If contractor, indicate type and license number X x X □ Architect□ Property Owner □ Contractor□ Billing Party □ Facility Owner If contractor, indicate type and license numberLast nameFirst Name State ZIPCityAddress EmailPhonePhone □ Contractor □ Architect□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party If contractor, indicate type and license numberLast nameFirst Name State ZIPCityAddress EmailPhonePhone DATE: PROPERTY / BUSINESS OWNER □ OTHER AUTHORIZED AGENT Title Linked FA IDAssigned ToAccepted By Contact Types required □ Application for Operating Permit 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._________________________________________________ Type of Service Requested Comments Consul VcvH oh If mobile food truck or pumper truck J 'hr?a □ Facility Contact Last name . , A/ Supervisor District S,ad^ Fir&Name, . cr Email San Joaquin County Environmental Health Department Application Form may /0 BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the worlvto be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. . v- // , > S"" < APPLICANT'S SIGNATURE: *--— DATE: □ OPERATOR / MANAGER Date(D"S\\a)\2</ Facility Name . SiteAddress, */-/?/ APN Record Number State . _____F- _________ Fee ^1(^2 | JePP c.____ peM2>