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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> 7- <br /> Site Address G`r^2 L s� City(� State (A ZfP 2-O� <br /> APN �II� Supervisor District <br /> Type of Service ❑Application for ❑Consultation Change of owner ❑Repairs or Remodel D Other <br /> Requested Operating Permit <br /> Comments <br /> V\C"'Vkc C C,-� p <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 /> Billing Party ❑Facility Owner ❑Facility Contact 70 Property Owner ❑Contractor ❑Architect <br /> First Name IRP Last name If contractor,indicate type and license number <br /> V; S�AP-mn <br /> Address City State ZIP <br /> q(12-1 ID A 4INC.I► C-�z\\ c STt M-ror-3 0:11 q 2D1 <br /> Phone Phone Email <br /> (-11-`il2• <br /> U Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor El Architect <br /> First Name Last name 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 11 Contractor ❑Architect <br /> First Name Last name It contractor,indicate type and license number <br /> Address City State <br /> Phone Phone Email <br /> Phone T ►j /�® <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge and/o ct <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or �T AM5 FeW this <br /> form. �^f �+ N� e Cod <br /> I also certify that I have prepared pptfcation t the work to be performed will be done in accordance with all SAN JOAQLIIN COTJ �(e Codes, <br /> Standards,STATE and FEDER C laws, MEHT <br /> APPLICANT'SSIGIVATURE: O� f ��fATE: I <br /> PROPERTY/BUSINESS OWNER 0 OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT nRI-, <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 HFALTFI <br /> DEPARTMENT as soon as it is available and at the same time it Is provided to me or my representative. <br /> Accepted By Assigned To Linked FA ID C) t �� <br /> t ��!'f VIES C CI 13"i ke ?"t <br /> Date,+nr^L PE �} F Record NumberI <br /> Y` n Payment <br /> ❑Cash ❑Check.# Confirmation# ✓1([J Received By <br /> �( <br /> Rev 07/10/2024 V�Z N3� <br />