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J New Facility □ Existing Facility Site Address City State ZIP LAAPN □ Consultation □ Change of Owner □ Repairs or Remodel □ Other License Plate Number VIN □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect First Name If contractor, indicate type and license numberr Address State CA com □ Facility Owner □ Property Owner □ Contractor □ Architect First Name If contractor, indicate type and license numberLast name Address City State ZIP Phone Phone Email □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect If contractor, indicate type and license numberFirst Name Last name Address StateCity ZIP EmailPhonePhone DATE: □ OTHER AUTHORIZED AGENT □ PROPERTY / BUSINESS OWNER □ OPERATOR/MANAGER JAN 1 5 2026Title Linked FA IDAccepted By Assigned To FeeDate > IT5 □ Cash □ Check it Rev 07/10/2024 ^2^000^^- wi2A\va.<< San Joaquin County Environmental Health Department Application Form Contact Types required If mobile food truck or pumper truck □ Application for Operating Permit Payment Received By RECEIVED 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 COUN' Standards, STATE and FEDERAL laws. A/ / /o / APPLICANT'S SIGNATURE:" 1 DATE: / / / / / □> / Type of Service Requested Comments Phone □ Billing Party (vfConfirmation U If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site addrgs^Ja WVjW'dbLlNTY release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIl1UN0 DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.HEALTH DEPARTME Phone Email □ Facility Contact Facility Name LCk (OS La Iwm______ S Sv. Supervisor District 2 R.jy, UldiV Last napie ZIP PE