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□ Existing Facility San Joaquin County Environmental Health Department Facility Name StateSite Address CA APN □ Consultation □ Change of Owner □ Repairs or Remodel □ Other License Plate Number VIN □ Facility Contact □ Property Owner □ Contractor □ Architect□ Billing Party □ Facility Owner H Facility Contact^Facility Owner □ Contractor □ ArchitectBilling Party □ Property Owner If contractor, indicate type and license numberLast nameFirst Name State ZIPAddress,.CH □ Contractor □ ArchitectEf Billing Party □ Property Owner If contractor, indicate type and license numberLast name 'hone □ Architect□ Contractor□ Property Owner□ Facility Owner Last nameFirst Name City StateAddress EmailPhone OC ’ 0 7 2025Phone DATE: □ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGER□ PROPERTY / BUSINESS OWNER Title Linked FA IDAssigned ToAccepted By □ Confirmation tt□ Check tt Rev 07/10/2024 Contact Types required 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.________________________________________________ Ei/Application for Operating Permit State cn- Date>07-35 f^/sh If contractor, indicatp^>y|^|yty^i*y>ber Type of Service Requested Comments Application Form La CoLantx De, \/il\a to on‘An A0- H -5t| “Kn-K.- Supervisor District basrnfng vj union g.A. .Phone . Phone BTFacility Owner If mobile food truck or pumper truck tzf^ew Facility fl \| V&Araza Fe^537 Vidcd Pedrgra PEldOI fipJ- H-31 Email . CStFacility Contact BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, ackno’SlAN. specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL lawsrr- . . t \ . \ ^'APPLICANT'S SIGNATURE: I fL?, TV- H Q. DATE: jV M end _____ CltyA 4 City □ Facility Contact IA g.rn^n J Vj uni OVA 38 I □ Billing Party Recorcl Numb^r^^ 3,”?■ 7 Payment /JC Received By / First Name ' t^OvVASlCO