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X New Facility □ Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name Ove Hcyrcr*1 ec □ Consultation □ Change of Owner □ Repairs or Remodel □ Other License Plate Number VIN □ Architect□ Facility Owner □ Facility Contact □ Property Owner □ Contractor□ Billing Party ^Billing Party Facility Owner □ Property Owner □ Contractor □ Architect□ Facility Contact If contractor, indicate type and license number Phone □ Architect□ Property Owner □ Contractor□ Facility Contact□ Facility Owner□ Billing Party If contractor, indicate type and license numberLast nameFirst Name State ZIPCityAddress EmailPhonePhone □ Property Owner□ Facility Contact□ Facility Owner□ Billing Party Last nameFirst Name CityAddress EmailPhonePhone DATE: □ OTHER AUTHORIZED AGENT □ OPERATOR / MANAGER□ PROPERTY / BUSINESS OWNER Title Linked FA IDAssigned ToAccepted By VAcIcaJI P State on Contact Types required 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._________________________________________________ City ZIP 95239 ZIPSite Address APN Last name City State 6YY Type of Service Requested Comments Record Number ______________ First Name ^OYYin___________ Address Phone OH ju CuJr) Aug Supervisor District ^Application for Operating Permit MFF Pl<xn fteview If mobile food truck or pumper truck Jeff C PE Email r run, A 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 FEDERAtTpws. . .—. . -j i "> tC ? UAPPLICANT'S SIGNATURE: f\OXXU I () \)l DATE: .. Y---A J---------------------------- ------------------ Architect license number -um------- _______ Q10 □ Contrp^ECEl\/fifP If contractcyyi^icgt&yi