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□ New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Site Address State QA_1 <br />APN <br />^.Change of Owner□ Consultation □ Repairs or Remodel □ Other <br />License Plate Number VIN <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />>3 Billing Party Facility Owner □ Property Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license number <br />Address <br />Phone <br />□ Billing Party □ Facility Owner □ Property Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address City State ZIP <br />Phone Phone Email <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor <br />First Name Last name <br />Address City State <br />Phone Phone Email <br />Hhw V >■DATE: <br />□ OPERATOR/MANAGER □ OTHER AUTHORIZED AGENT □ PROPERTY / BUSINESS OWNER <br />Title <br />PE <br />□ Cash □ Check U <br />Rev 07/10/2024 <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 />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />□ Application for <br />Operating Permit <br />ZIP <br />' 2025 <br />^Facility Contact <br />Type of Service <br />Requested <br />Comments <br />-----------!----------------- <br />Phone Email <br />□ Facility Contact <br />Last name , <br />1^175 <br />Linked FA ID <br />Record Number <br />^.Confirmation U Q | <br />S /"X ’^~1 lc\ Quai \ <br />Supervisor District <br />Accepted By <br />VtdoJ- P- <br />bVm Iz-S <br />State a <br />& <br />Existing Facility <br />^^07 <br />Payment I <br />Received By^l----- <br />If contractor, number <br />406 1 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge project <br />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 laws. r-'i . \ ' <br />APPLICANT'S SIGNATURE: IftH l)h\-\uk Z____________________________ DATE: C' ' \ - <br />Assigned To <br />LcyJaCv yp. <br />Feein°i .©<£>