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❑ New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address h✓*f� r� Cikyq, Skate n ZIP -W3 <br /> APN Supervisor District 7 [+ <br /> Type of Service FlIppNcation for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number1� (� fy //� VIN T J� <br /> pumper truck =j JV Y 4" l�SGJO <br /> Contact Types C7 Billing Party Q FacllityOwner ❑Facility ContactJ_C' <br /> Property.Owner I�Contractor ID Architect <br /> requlfed <br /> Biking Party 2rFacility Owner ❑Facility Contact Q Property Owner II Contractor ❑Architect <br /> First Name Last name if contractor,indicate type and license number <br /> Address _ r f4 I � e city State ZIP ! <br /> Phone Phone f[I h ! ail 5) <br /> ❑Billing Party ❑Facility Owner 0 Facility Contact ❑Property Owner ❑Contractor Q Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Parry ❑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:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that ail site and/or project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourty charges associated with this project or activity will be billed to me or my business as identified on this <br /> form. <br /> 1 also certify that I have prepared this application and that the work to b rformed will be done in accordance with all SAN JOAQUIN COUNTY Or9c�Codes, �/ <br /> APPLICANT SSIGNATURDERAL laws DATE: _ ! J (_ Rr��IM�r i T <br /> IQPROPERTY/BUSINESS OWNER B OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT i w <br /> Title LJ S `' ?0� <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required 1 <br /> AUTHORIZATION TO RELEASE INFORMATION.When applicable,I,the owner or operator of the property located at the above site addre��iar;ze the <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENV (JAI <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> Accepted By I V)(A ` Assigned To �� �� � Lhi A <br /> Date � �I � PE � �, � Fee <br /> Payment <br /> C3 Cash 0Check# SY!�/ �24 d (-CC)Confirmation p 0Received ey� Li ' <br /> I (�f <br /> Rev 07/10/2024 /��� (, 5� E 7 —3 <br />