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❑ New Facility San Joaquin County Environmental Health Department Application Form Existing Facility (needs SR#) Facility Name 6(1 Billing Party ❑Facility Owner ®Facility Contact ❑Property Owner ®Contractor ®Requester required If contractor, indicate type and license number Address City State Site Addre Phone Phone Email City t State Last na0 ZIP lit Address CIM , LJ) State ZIP t j APN Supervisor District Phone Phone Email Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner ❑ Repairs or Remodel ❑ Other Requested Operating Permit Comments01 If mobile food trucA or License Plate Number VIN pumpertruck Contact Types 6(1 Billing Party ❑Facility Owner ®Facility Contact ❑Property Owner ®Contractor ®Requester required If contractor, indicate type and license number Address City State ZIP Phone Billing Party El Billing Party El Facility Owner 11 Facility Contact ❑Property Owner El Contractor ❑ A s ❑Facility Owner ❑Facility Contact ❑Property Owner or�ractor ❑Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email First Name C Last na0 if contractor, indicate ype and license number lit Address CIM , LJ) State ZIP t j Phone Phone Email ❑ Billing Party ❑Facility Owner ❑facility Contact ❑Property Owner 11 Contractor itect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email BILLING ACKNOWLEDGEMENT: I, the undersigned propert ❑Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email y 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 protect or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this,-pli tion and that the work to be performed will be done in accordance with all SAN /JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL law$/ ,� ,/', A J / / a <'- APPLICANT'S SIGNATURE: L DATE: �� J PAY r�: Com- AA NT ❑ PROPERTY /BUSINESS OWNER ❑ OPERA70R /MANAGER OTHER AUTHORIZED AGENT(V1�k��C�� Title ED If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, the owner or operator of the property located at the above site address, hereby a �ri(p�e 1JV 8 release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALhi l01 �Q25 DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. am JinA^..._ _ Accey[ed ByC i, Datel 2 , ❑ Cash Rev 07/10/2024 ❑ Check # Assigned 41 AV Linked FA ID HCS; TM L FAVmW g55 HEA'" 'am Re5Ra51Z11a3 confirmation # a 1 oZ 401oq 4I N Payment Received By