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IH New Facility Existing Facility <br />Facility Name <br />Site Address City State ZIP <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />Billing Party Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />c <br /> Billing Party Facility Owner Property Owner Contractor <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 'Ct <br />i{^e numberFirst Name Last name <br />Address City <br />Phone Phone Email <br />jpn and that tl <br />DATE: <br /> PROPERTY / BUSINESS OWNER OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br />Title <br />Linked FA ID <br />PE <br /> Cash Check ft <br />Rev 07/10/2024 <br />San Joaquin County Environmental Health Department <br />Application Form <br />Contact Types <br />required <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 />If mobile food truck or <br />pumper truck <br />Payment <br />Received By <br />Mo nfeco, <br />Phone Fv <br />P3 Facility Owner <br />Type of Service <br />Requested <br />Comments <br />W? syJoYVXyHed <br />VIN <br />Isor District <br />$ Application for <br />Operating Permit <br />Rexaeu/ fix <br />License Plate Number <br />cA_______( <br /> Contractor Architect <br />Sun< <br />^5 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or 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 applii <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: / <br />Email <br />(a j <br /> Facility Contact <br />Accepted By□ePF c- <br />work to be performed will be done in accordance with albSAN JOAQUIN COUNTY Ordinance Codes, <br />f^ne (_/liA' <br />Assigned To <br />i F• <br />Fee <br />$ b 33- ■ (TO <br />Record Number <br />_______________2-^05' <br />^Confirmation ft <br /> Contractor fi^CP <br />If contractor, indicate typl <br />-----JUL 3 1 <br />State- ' <br />SaN jQt- -