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t^New Facility □ Existing Facility San Joaquin County Environmental Health Department Application Form Facility e State □ Consultation □ Change of Owner □ Repairs or Remodel □ Other VIN ^Billing Party ^Facility Owner ^Facility Contact S(Property Owner □ Contractor □ Architect -0 Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect Last name If contractor, indicate type and license number Phone □ Facility Owner □ Property Owner □ Contractor □ Architect Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect If contractor, indicate type and license numberLast name Address City State ZIP Phone Phone Email DATE: □ PROPERTY / BUSINESS OWNER □ OPERATOR / MANAGER □ OTHER AUTHORIZED AGENT Title Linked FA ID Fee m;\'oO2 z ^Confirmation tt□ Cash □ Check U ’__I Rev 07/10/2024 Contact Types required □ Application for Operating Permit enA pe/(x<~V Payment Received B1 ZIP CoJ City ZIP Date City State □ Billing Party First Name □ Billing Party First Name Email □ Facility Contact Our License Plate Number ■» H co Type of Service Requested Comments v r If mobile food truck or pumper truck Supervisor District BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL lawsT) zi - i'-v n (• IT i APPLICANT'S SIGNATURE: ( U CJL DATE: I C- U- 7'S __ Number £1280'^0 ' tome Site Address APN ' ^ECpiuNt ‘''-n the Assigned To ________ \ i Accepted By PE First Najpe Address fejy -SOSVi Phone 7,^ - yo If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required PlPr AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site addre5s~iiLrel// Ajlhaua: t release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTlS^MIRONMENTAL HEAiZtv DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. p\7^ql ll/u