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New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Site Address State ZIP <br />CA 5^03 <br />APN <br /> Repairs or Remodel Other Consultation Change of Owner <br /> Facility Owner <br />^Facility Contact Contractor Architect Property Ownertilling Party <br />rnie If contractor, indicate type and license numberLaste <br />I Cl <br />StateAddress <br />Phone <br /> Contractor Architect Facility Contact Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />State ZIPCityAddress <br />EmailPhonePhone <br /> Architect Contractor Property Owner Facility Owner Facility Contact Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPCityStateAddress <br />EmailPhonePhone <br />MAR 0 8 ZqZG OTHER AUTHORIZED AGENT OPERATOR / MANAGER PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAssigned ToAccepted By <br />Fee <br /> Check « Cash <br />Rev 07/10/2024 <br /> Property Owner <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />Supplication for <br />Operating Permit <br />-Ur <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 havgj <br />■.SLandf^f <br />APPLICANT'S SIGN ATUH <br />Date <br />:ed^js application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY OpA-Y^AE^^" <br /> date: received <br />Type of Service <br />Requested <br />Comments <br />Or Y-C' <br />730 1 <br />1 c/? <br />Lijdi a <br />NJeuQ -Vo <br />| License Plate <br />Barer <br />Z I I O.WW Y <br />i^fconfirmation « | | <br />\/ jricil Pec?raz^ <br />PE ifcoa <br />o’ 0 ^li •rCr fl ire St- -ocK-kxw <br />Supervisor District <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required ,q <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENT?Mr <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.HEALlI <br />a <br />UIN COUNTY <br />Mental ^partment <br />I Property Owner <br />45^$Cxisting Facility <br />V,NieBHP^ 2K1. 5 530)3 <br />Record Number <br />/\PaG)Q30(b4 <br />I Payment <br />Received By( <br />, Contractor | Architect Facility ContactI Billing Party <br />| Q^acility Owner <br />Phone Email .