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□ Existing Facility San Joaquin County Environmental Health Department Facility Name City ZIPSite Address 95,330 APN pother□ Change of Owner □ Repairs or Remodel□ Consultation VIN □ Facility Contact □ Contractor □ Architect□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect□ Facility Owner□ Billing Party Last nameFirst Name Address □ Facility Contact □ Property Owner □ Contractor □ Architect□ Facility Owner□ Billing Party If contractor, indicate type and license numberLast nameFirst Name City StateAddress ZIP EmailPhonePhone □ Property Owner □ Contractor□ Facility Contact □ Architect□ Facility Owner□ Billing Party Last nameFirst Name City StateAddress EmailPhonePhone DATE: □ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGER Title Assigned To Fee □ Check H□ Cash Rev 07/10/2024 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. Contact Types required □ Application for Operating Permit Email icjxid Com Date tooA p If mobile food truck or pumper truck Phone Phone Sf New Facility Type of Service Requested Comments Application Form Pcfen, La \ioW\ Vs'D Supervisor District 1AVINUO5License Plate Number □ Property Owner LWwt- If contractor, indicate typflyQ number 2 / o BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknOT^JsIjmSQj^LmQt^P^^ct specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or myt yi 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. I T O f 'I APPLICANT'S SIGNATURE: DATE: cLJ J L'J B/PROPERTY / BUSINESS OWNER If contractor, indicate type and license number ZIPcm^ Linked FA ID Record Number , AP25a>2Qfe3 Confirmation # 2)93 State xs i __CA Accepted By , . _______i PE \toO\ sure Payment z~\ . Received By C/l/