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El New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form ?(2- o `l9 <br /> FacTy a ,r [ <br /> Site Address l{/� City State �i ZIP <br /> (APty supervisor District <br /> Yi 1 r <br /> Type of Service pplication for ❑Consultation Change of Owner ❑Repairs or Remodel ther <br /> Requested Aerating Pefmlt <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types Cl Billing Party 0 Faclity Owner Q Facility Contact ❑PropertyOwner ❑Contractor ❑Architect <br /> rmulred <br /> Billing Party Facility Owner cility Contact Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> I <br /> r s � a ` �j ity Stale I1P <br /> I[v v <br /> hone- Phone Email <br /> 1 +tib 2t <br /> Q Billing Party ❑Facility Owner 0 Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last nae If contractor,Indicate type and license number <br /> m <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility owner ❑Facility Contact ❑Property Owner ❑Contractor <br /> First Name Last name if contractor,Indicate tVTwW 101�Urnber <br /> M <br /> Address City State saN JO ZIPIO�6 <br /> Phone Phone Email h��rHRpMM Co�N <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that a /or project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated wi is project or activity will be billed to me or...,business as identified on this <br /> form. <br /> I also certify that I have prepared this application d that the work to performed will b ne in accordance with all SAN JOAQUIN COUNTY ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APP///L///ICA 'rS SIGNATURE: GATE: III LGA <br /> �YRQPERTY/BUSINESS OWNER ❑O ERATOR AGER ❑OTHER AUTHORIZED AGENT <br /> lJ�� Title <br /> If APPLICANT is not the BILLING PA ,proof c authori Ion to sign is required <br /> AUTHORIZATION TO RELEASF INFORMATION:When applicable,I,the owner or operator of the property Located at the above site address,hereby authorite 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 rn reresentitive. <br /> Accepted By \_ Assigned To Linked FA 10 <br /> Date Record Numtxr 0 `l� <br /> 3 2 b PE Fee 1 _ V fe t <br /> Payment <br /> ❑Cash ❑Check Monfirmatlan q 2i 1O Received By <br /> Rev 07/10/2024 rr <br />