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New Facility Existing Facility San Joaquin County Environmental Health Department Facility Name Site Address City APN MChange of Owner Consultation Repairs or Remodel Other License Plate Number VIN Billing Party Facility Owner Facility Contact Property Owner Contractor Architect H Facility Owner Facility ContactBilling Party Property Owner Contractor Architect If contractor, indicate type and license number Billing Party Facility Owner Facility Contact Property Owner Contractor Architect If contractor, indicate type and license numberFirst Name Last name Address City State ZIP Phone Phone Email Billing Party Facility Contact Property Owner First Name Last name Address StateCity Phone EmailPhone DATE: OPERATOR/MANAGER OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER Title Assigned ToAccepted By Ba Ker Confirmation H Check tl Rev 07/10/2024 City Email 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. If mobile food truck or pumper truck Application for Operating Permit Contact Types required ZIP ^5304 ZIP q si-fa 3 Fee State CA ___________Application Form T"a.rasco Foods Date 1 Type of Service Requested Comments 3333 Delaware Ave. Supervisor District --------PAYMENT □“"'r^t'RECEiVEU" If contractor, in^tj^te^y^j? ai^l^gnse number ZIP SAN JOAQUIM COUNTY ----ENVIRON* ENTAL- HEALTH DEPARTMENT Last name . 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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws>. 1 O APPLICANT'S SIGNATURE: \ DATE: | | I First Name ___ Address h -PhoneI Phone LSSUAST-qBj | Facility Owner State CA Je-CF C- Linked FA ID _ FA0Q> 14 57-4 Record Number5R.aG01^t<2 Payment Received By