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(^Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />State CA <br />APN <br /> Other Repairs or Remodel Consultation <br />License Plate Number or <br /> Architect Contractor Property Owner Billing Party Facility Owner Facility Contact <br />^Facility Owner Architect Contractor Billing Party Property Owner Facility Contact <br />If contractor, indicate type and license number <br />ZIPStateAddressCf\^53^ £ <br /> Architect Contractor Property Owner Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPStateCityAddress <br />EmailPhonePhone <br /> Contractor Property Owner Facility Contact Facility Owner Billing Party <br />Last nameFirst Name <br />StateCityAddress <br />EmailPhonePhone <br /> DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR / MANAGER <br />Title <br />Accepted By <br /> Check# <br />Rev 07/10/2024 <br />■Jiyrmiiinrii <br />C \ r\V\c>\r-€=>_s <br />PE <br />Contact Types <br />required <br />If mobile food truck <br />pumper truck <br />VfApplication for <br />Operating Permit <br />Phone <br />Last name <br />Confirmation# <br />m Change of OwnerType of Service <br />Requested <br />Comments <br />VIN <br />Email <br /> Facility Contact <br />First Name <br />s pazcMt CM <br />Phone <br />c<-J <br />^ PROPERTY / BUSINESS OW^fcR <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 />________ ___ ____________________________________ ________________f <br />"bIlUNG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with thij^roject or activity will be billed to me or my business as identified on this <br />certify that I have prepared this application ^d Uf^the^ork to be pe^ed will be done in accordance with all SAN KJAQUIN COUNTY Ordinance Codes. <br />Standards, STATE and FEDERAL laws. x / <br /> APPLICANTS SIGNATURE: DATE- --------f / J-------- --------------------- <br />Assigned To <br />Fg)OS. sc <br />If contractor, indicate type ^r|cense number <br />/ 5 <br />Facility Name ------------------------------------- <br />Ellis <br />^71^ c t) <br />Record Number _ n <br />SR2(^(?2-663 -.-rt <br />Payment z/7/\ <br />ySb Received By Q <br />Site Address <br />2-2 2 7 N fyLVO <br />Supervisor District