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L New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name Y V" <br /> Site Address t y k1Ll/ City State ZIP <br /> 730 5 T ,� Yszo <br /> APN Supervisor District <br /> Type of Service WApplication for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments1 <br /> &kl +f-11L, <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck A 5'4/ -13(kl 6 Z 75POI -5 <br /> Contact Types ❑Billing Party ❑Facility Qwner ❑Facifity Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> filling Party GS Facility Owner acfiity Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name last na e <br /> If contractor,indicate type and license number <br /> r <br /> dL <br /> Address City State ZIP <br /> � >�- S�a,✓ � s zo <br /> Phone Phone Email <br /> V Ll <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 ❑Al+A' eft <br /> Last name If contractor,indicate type abe <br /> First Name V <br /> Address City State1.""' <br /> 2 5 <br /> XA _202g <br /> Phone Phone Email N�I�Aprj.,�CDU <br /> H41 <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and <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 ap tion and at the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDfRAI laws. <br /> AP <br /> �PLICANT'SSIGNATURE: DATE: 3-7Z <br /> 1 PROPER'T'Y/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT O r✓rer <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 Linked FA ID <br /> Date Pf { Fee t.11 Record Number 6?2 (0O�1 O2— <br /> � ll�lr G <br /> Payment <br /> ❑Cash ❑Check# Confirmation# 5 2 L— Received By <br /> Ziff <br /> Rev 07/10/2024 ?p2v 00-22-61 <br />