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❑ New Facility I& Existing Facility <br /> San Joaquin County Environmental Health Department : <br /> Application Form �o��o`� e <br /> Facility Name <br /> .4 <br /> Site Address City State ZIP <br /> FastS'� ��aC C A� qr <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation 0 Change of Owner ❑Repairs or Remodel ❑other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number V1N <br /> pumper truck <br /> Contact Types ❑Billing Party Xfadhty Owner 0 Facility Contact ❑Property Owner 0 Contractor ❑Architect <br /> required <br /> ❑Billing Party MFacility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,Indicate type and license number <br /> U CJL ' C <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party MFacillty0wner ❑Facility Contact Cl Property Owner O Contractor ❑Architect <br /> First Name Last name if contractor,Indicate type and license number <br /> Address City State ZIP <br /> Phone '1 Phone Email <br /> ❑Billing Party ❑Facility owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Nam` Last name If contractor,indicate typA hcense <br /> EIVED <br /> Address City State ZIP C <br /> Phone Phone Email <br /> SAiN Jo <br /> EH <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of some.acknowled fEAh <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this projector activity will be billed to me or my business as ideMi a Nr <br /> form. <br /> I also certify that I have prepared this application and that tale work to be performed will be done In accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws r1 <br /> APPLICANT'S SIGNATURE; _ DATE: <br /> CS PROPERTY/BUSINESS OWNER ❑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,I,the owner or operator of the property located at the above site address,hereby authorl2e 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 represeniative <br /> A"O'd"I Vidal Pedraza A�nirdT° Kademml Linhares UnkedFAID <br /> Date rj/1/202E=1 <br /> 2 Fee 179 Record Numherlrj /_/l�l <br /> Rev 06/12/2024 <br /> Pilylllell{ 22{)I I 1895 <br /> 0 <br />