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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address City State ZIP <br /> 5T dA 4 syi f <br /> APN Supervise istrict <br /> Type of Service ❑Application for ErConsultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> ",. -, � <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> B"Billing Party ❑Facility Owner ❑Facility Contact Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> a- C � f OG S o <br /> Phone Phone Email <br /> 0 ' <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner Vcontractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> ,c5 <br /> Address Ci State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> BILLING ACKNOWLEDGEMENT:I,the undersi ned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project <br /> specific ENVIRONMENTAL HEALTH DEPART E T hourly charge sociated 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 a lic ion and tha h k to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: ��02 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER THER AUTHORIZED AGENT �{�/L�/V(,��l�I � _ <br /> TitleM�N� <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is re. <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,R&C�' Q1 <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTIi <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. r- <br /> Accepted By, � Assigned To �hL Linked FA ID SAN JOAQUIN COU <br /> At <br /> Date '7 fEX <br /> F 4�(r I�— Record Number H r <br /> elm <br /> Payment <br /> ❑Cash Check# 12 ❑Confirmation# Received B <br /> Rev 07/10/2024 J <br />