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New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form _ <br /> Facility Name ) Ltcf & — <br /> Site Address City 4state NJ ZIP <br /> APN Supe isor District <br /> Type of Service Application for ❑Consultation El Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number I VIN <br /> pumper truck I /J <br /> Contact Types KRilling Party ❑Faci'Ity owner ❑Facility Contact ❑Propert)LO*ner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner i ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> �r �•UA� <br /> Address City State ZIP <br /> Phone 4 Phone I Email <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 ❑Architect <br /> First Name Last name If contractor,Indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> BILLING ACKNOWLEDGEMENT:1,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 have prepared this a cation an hat the work to be performed will be done in accordance with a I SANJJAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL law L <br /> APPLICANT'S SIGNATURE: DATE: <br /> ❑PROPERTY/BUSINESS OWNER [1 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,1,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 �D linked FA ID <br /> Date/2 l 12 F �X R�MumherPF <br /> ❑Cash ❑Check III ❑Confirmation IIIPaymentReceived By <br /> i <br /> Rev 07/10/2024 <br />