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❑ New Facility [/Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Fatuity Name <br /> Site Address Cit State ZIP <br /> S ' O yl7 <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> R%i P c±T f V4-rl 1;- <br /> If mobile food truck or Li ease Plate Number VIN <br /> pumper truck 1414V J{�* C:_-� <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party El Facility Owner ❑Facility Contact ©Property Owner ❑Contractor ❑Architect <br /> moo First Name Last name if contractor,indicate type and license number <br /> Address6}} City State ZIP <br /> Phi] a Phone Email <br /> E]Billing Party ❑Facility Owner Q 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 *one Email <br /> Q Billing Party J ❑Facility Owner ❑Facility Contact y Owner ❑ El Architect Q Propert <br /> First Name Last name if contractor,indicate type a d i s T <br /> Address City state ZIP I <br /> Phone Phone Email I <br /> SAN <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowled IAEct , <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as i taitIA or <br /> form. <br /> 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, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: s DATE: Zz <br /> � y <br /> Q PROPERTY/BUSINESS OWNER ❑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 �/Z p T C' ` Assigned To o L /N n-�.S Linked FA ID -FA-0 0 1Date PE Fee Record Number <br /> y f � 3 1 -71 Z � 75 <br /> Payment <br /> YCA <br /> 7 z 60 I]Check# _.,nfirmation# Received By <br /> Rev 07/10/2024 <br />