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^Existing Facility New Facility <br />-San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Site Address <br />APN <br /> Other Change of Owner Repairs or Remodel Consultation <br />VIN <br /> Contractor Facility Contact Architect Facility Owner <br /> Architect Property Owner Contractor Facility Contact Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />Addre: <br />Email <br /> Contractor Architect Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPCityStateAddress <br />EmailPhonePhone <br /> Contractor Property Owner Facility Contact Facility Owner Billing Party <br />REi <br />iberLast nameFirst Name <br />City StateAddress <br />EmailPhonePhone <br />ei <br />k'DATE: <br /> OTHER AUTHORIZED AGENT OPERATOR / MANAGI PROPERTY / BUSINESS OWNER <br />Title <br />3 Confirmation fl <br />^01^^Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <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 JOAQ.UIN 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 />OUNTY <br />tal <br /> Check H <br />Type of Service <br />Requested <br />Comments <br />______cltvJhc/<^ <br />MN / - CffYT] <br /> Facility Contact Property Owner <br /> Application for <br />Operating Permit <br />truck or License Plate Number <br />Supervisor District <br />Record-Number <br />Payment <br />Received By <br />Cf< pr <br />Accepted By^/"! b-'\ A <br />—J/ <br />rd willybe done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Property Owner Billing Party <br />s,a,e <br />state <br />Assigned Tj> r <br />FM <br />went <br />If contractor, indicate typTa^^^^^Oni <br />-—2026 _________sfc <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 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 application and that the work to <br />Standards, STATE and FEDERA^rys. . /Ti . / <br />APPLICANT’S SIGNATURE: \ X /