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I^t-New Facility □ Existing Facility San Joaquin County Environmental Health Department Application Form Supervisor District □ Consultation □ Change of Owner □ Repairs or Remodel □ Other □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect If contractor, indicate type and license numberLast name State Email □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect If contractor, indicate type and license numberFirst Name Last name ZIPAddressCityState EmailPhonePhone □ Property Owner □ Contractor□ Billing Party □ Facility Owner □ Facility Contact First Name Last name Address City EmailPhonePhone fplicatii DATE: □ OTHER AUTHORIZED AGENT |R / MANAGER□ PROPERTY / BUSINESS OWNER OPEI Linked FA IDAssigned ToAccepted By Date \ HI 2>a□ Check H□ Cash Rev 07/10/2024 If mobile food truck or pumper truck Contact Types required 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 address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTII DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. □ Application for Operating Permit VIN E'Xg.X 7-P4 83-1 Payment Received By City I ZIP State Address Phone *em#>jromber ZIP -^26- E Confirmation tt Type of Service Requested Comments License Plate Number □ Billing Party Title If contractor, indO"^ ^tSAr^itecl ind that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, 1 I | City z'P^ko First Name i Phone PE IU>o3 State ------------------------ ____________________________________________Tk ____ BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge-^^ ^11 srtb and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business'J&id^ified on this form. I also certify that I have prepared this Standards, STATE and FEDERAL laws. < APPLICANT'S SIGNATURE: ' Facility Name ______Luc Si,W A/ ^Id APN