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1 <br /> ❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name C�0 OCA,'tii C� G1 <br /> Site Address Ci State ZIP Y <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel E Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number ViN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Prpperty Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facllity Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> 31 y 3 <br /> Phone_ Phone Email <br /> r <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor Re Jr L1jei <br /> First Name Last name If contractor,indi to type and i e r her <br /> CEP <br /> Address City State SAN <br /> Phone Phone Email NJEE4J~jNNOAJO <br /> �N VU T,1� TM <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 LNVIRONMEN IAL 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 application and that work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDE aw ( _ l2C <br /> APPLICANT'sSIGNATURE: DATE: �1 Z� J <br /> ROPERTY/BUSINESS OWNV ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <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 /> Accepted By Assigned To C Linked FA ID <br /> i 1 <br /> Date I�O PE Fee Record Number 4 <br /> � � 6 <br /> Payment <br /> KCsh ❑Check to ❑ConfirmaVon# Received By <br /> Rev 07/10/2024 <br />