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VNew Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> TndioLn Pare `Bas a Kh; e t a <br /> Site Address City state ZIP <br /> -7 10 E. Wood ward A v It Mi'Jl.Yl+tcot- CA Q5 3 3-7 <br /> APN Supervisor District <br /> Type of Service Application for ❑Consultation Q Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> �Ilfmobile food truck or License Plate Number VIN <br /> mper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor 0 Architect <br /> required <br /> Biking Party Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor F❑_Architert <br /> ' ame i If contractor,indicate type and license number <br /> Phone slmail // <br /> 1 p a L a1 "O• -4", <br /> ❑Billing Party ❑Facility Owner 0 Facility Contact ❑Property Owner ❑Contractor 0 Architect <br /> First Name Last Hama 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 ❑ArchiteyL <br /> First Name Last name If contractor,indicate type and lic <br /> Address City State ZIP OR <br /> Un <br /> Phone Phone Email lQq/N � <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or ��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 COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL <br /> APPLICANT'S SIGNATURE- <br /> 0 PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization 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 /> Accepted By �Q Assigned To LT�l Linked FA ID <br /> I I F. <br /> Date PE Fee er <br /> a5 � � or � -7 , Record Nu pa50 185 I <br /> Payment <br /> ❑Cash ❑Check P —' 0 Confirmation If ,�, Received By <br /> Rev 47/10/2424 <br />