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□ New Facility □ Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name ZIPSite Address City State APN □ Other□ Change of Owner □ Repairs or Remodel□ Consultation □ Property Owner □ Contractor □ Architect□ Billing Party □ Facility Contact □ Architect^Facility Owner □ Property Owner □ ContractorSTBilling Party Facility Contact If contractor, indicate type and license numberFirst Name Phone □ Contractor □ Architect□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party If contractor, indicate type and license numberLast nameFirst Name City State ZIPAddress EmailPhonePhone □ Contractor□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party Last nameFirst Name StateCityAddress EmailPhonePhone DATE: □ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGER Title Linked FA IDAssigned ToAccepted By Vidal Pedraza to be assigned (Q-f') "0^11FeePE1601537 Payment 210380223 Rev 06/12/2024 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 HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative._______________________________________________ ZIP ____7______ Supervisor District Type of Service Requested Comments License Plate Number z_______ ^facility Owner Ef Application for Operating Permit TI CO- ub di cb r _______ VIN /) State Last name Citu ._______LptrdxcA cXo ud. Address 3047 Phone Phone Email 91V b If contractor, indicate type andJJcense num 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 COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: 1 his i| . □ PROPERTY/BUSINESS OWNER I 10/21/25