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r <br /> ❑ New Facility 2"-Existing Facility <br /> r• <br /> San Joaquin County Environmental Health Department It\., <br /> Application Form <br /> Facility Name <br /> Site Address City State ZIP <br /> 'L <br /> APN ervisor District <br /> Type of Service IQ Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumpertruck LTZ1�" �� [ydgfvt t z k(31,+ <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party 0 Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Las name If contractor,indicate type and license number <br /> GV G i e G O <br /> Address City Staateh �ZIIP <br /> U \ t 1 U C \A) %M ael C rC ` tia -/ 3 <br /> Phone / hone Email , <br /> ❑Billing Party ❑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 IP _ <br /> ❑Billing Party Q Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor Ap b <br /> First Name Last name If contrac �ccaate typ afnd 20 number <br /> A C <br /> Address City State <br /> N��p �Nrq NrY <br /> Phone Phone Email ENr <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 ap li tion and that the work to be performed will be done in accordance wi all 5AN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> ❑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 authorize 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 representative. <br /> Accepted Assigned To Linked FA ID <br /> rf1 7,�� <br /> Date PE Fee Record Number <br /> -Z--, [Z c, u6 0 <br /> Payment <br /> ❑Cash ❑Check p Confirmation q - <br /> 1 6 Received B <br /> Rev 07/10/2024 � <br />