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Lff New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name kL <br /> I I-o, (�,, r a K A — <br /> Site Address30 C�,Q4() r r�� City r�,[� State CA— ZIP <br /> APN Supervisor District <br /> Type of Service ❑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 /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Fatuity Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> l0 Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name — Last name O sr a If contractor,indicate type and license number <br /> � 1 L 0 Cnt,) I i 0 T I <br /> Address O D S City state ZIP <br /> 3 L�e� nQ � LA) 0. y S�CK�o � C �4 . cjs2 / Z <br /> ` Phone Phone Email <br /> \\ o ) 2°l`fi- Sb -r-T 4,90 0 v-l- k•Cz''t'c <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 <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner LJ Contractor ❑Architect <br /> First Name Last name If contractor,indicat li Air rpe r <br /> Address City State ZlP <br /> J1 <br /> U O <br /> Phone Phone Email JAR <br /> !N <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge �btid/or project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as idi ton this <br /> form. <br /> 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, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANTS SIGNATURE:JK DATE:ON <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <br /> If APPL{CANT is not the BILLING PARTY,proof of authorization to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,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 avai#able and at the same time it is provided to me or my representative. <br /> Accepted By A igne To ID FA inked L <br /> P1(,, _,) �)G <br /> Date � PE tl�03 Fee � Record Humber <br /> ZZ Payment <br /> ❑Cash ❑Check 1< Confirmation p Received By <br /> ('� <br /> Rev 07/10/2024 f' -L&o 0 � <br />