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New Facility Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name UdWa's KWchen, ZIPSite Address “tv W>n APN Consultation Change of Owner Repairs or Remodel Other i Licen^sePlate Number Architect Property Owner Contractor Billing Party Facility Owner Contractor Architect Facility Owner Facility Contact Billing Party If contractor, indicate type and license numberLast name State Cfr Property Owner Contractor Architect Facility Owner Billing Party If contractor, indicate type and license numberLast nameFirst Name City State ZIPAddress EmailPhonePhone Property Owner Contractor Architect Facility Owner Facility Contact Billing Party If contractor, indicate type and license numberFirst Name Last name City State ZIPAddress EmailPhonePhone DATE: RECEIVl OTHER AUTHORIZED AGENT OPERATOR / MANAGER PROPERTY / BUSINESS OWNER Title Linked FA ID Confirmation tt Check II Rev 07/10/2024 P£2S(W3 Contact Types required If mobile food truck or pumper truck Application for Operating Permit PE First Name Type of Service Requested Comments El Facility Contact 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 FEDERAt'ftws. _ _ APPLICANT’S SIGNATURE: DATE: Z b 7 r.AtMENT D Supervisor District Record Number Payment Received Bi Assigned Togfodeann* L. Fefe3^-^ TT In ffltffhavxY e lUfr-z to & tycthoo Facility Contact Address Phone Pnone Qoq ________ Accepted By C Date i\! Cash T Property Owner City, _____StocktOAi If APPLICANT Is not the BILLING PARTY, proof of authorization to sign is required OCT RQ AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby aJth<J/iz3 thfil/Zu release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRQ^IMM^TAI HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.NCOUNTY State _ch • C O M