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❑ New Facility XExisting Facility (needs SR#) San Joaquin County Environmental Health Department Application Form Facility Name 4(l Billing Party ❑Facility Owner Site Address2� APN Supervisor District ®Contractor Ci State ZIP G• 09+-04043 �pp f�.Az ZIP First Name �; 1� Last name T� If contractor, indicate type and license number Type of Service If contractor, indicate type and ligep;e number ❑ Application for ZIP 1(Z ❑Consultation ❑ Change of Owner ❑ Repairs or Remodel ❑Other Requested Operating Permit Phone Phone Email Comments Ve ou If mobile food truck or License Platd Number VIN pumper truck 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. Contact Types 4(l Billing Party ❑Facility Owner ®Facility Contact ❑Property Owner ®Contractor ®Requestor required Address City �pp f�.Az ZIP First Name �; 1� Last name T� Billing Party q ❑ Billing Party ❑ Facility Owner ❑Facility Contact ❑Property Owner 11 Contractor 11 Architect ❑Facility Owner ❑Facility Contact ❑Property Owner Contractor ❑ Architect Last name If contractor, indicate type and license number Address City �pp f�.Az ZIP First Name �; 1� Last name T� If contractor, indicate type and license number Address nRV�� If contractor, indicate type and ligep;e number State ZIP 1(Z Pho Pon21 Em 'I3 )` r' _u .. 10 Phone Phone ❑ Billing Party 11 Facility Owner ❑ Facility Contact CI Property Owner 11 Contractor First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email If contractor, indicate type and ligep;e number AA Accepted By Assigned To � Linked FA ID Ml. F'A0002530 ❑ A PE2� O 49 Fee �/ , � L7 Record Number '24) Ro a 01793 ❑ Cash ❑ Check #Confirmation # nn 3 First Name Last name If contractor, indicate type and ligep;e number Address City State Phone Phone Email ou 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 a Iic n and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDER L laws. / APPLICANT'S SIGNATURE: DATE: ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT /y %r Title 4mo i 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. Rev 07/10/2024 2 of 6 Ir D 20 205� PE2� O 49 Fee �/ , � L7 Record Number '24) Ro a 01793 ❑ Cash ❑ Check #Confirmation # nn 3 Payment I ec �?� Received By Rev 07/10/2024 2 of 6 Ir D