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San Joaquin County Environmental Health Department <br />Facility Name <br />ZIP <br />APN <br /> Consultation Repairs or Remodel Other Change of Owner <br /> Contractor ArchitectI SeillingPatty Facility Owner Facility Contact Property Owner <br /> facility Contact Contractor Architect Property Owner <br />If contractor, indicate type and license number <br />ZIP <br />EmailPhone <br /> Contractor Architect Facility Contact Property Owner Billing Party <br />If contractor, indicate type and license numberI First Name Last name <br />State ZIPCity <br />Phone Email <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor <br />Last nameFirst Name <br />City StateAddress <br />Phone EmailPhone <br />DATE: <br />0 PROPERTY / BUSINESS OWNER 01 HER AUTHORIZED AGENT <br />litle <br />Accepted By Assigned To United FA ID <br />PE IbOl <br />I Address <br />____ <br />! Phone <br />| <br />If mobile food truck or <br />Dumper truck <br />Phone <br />1.510 6 W <br />Contact Types <br />requirec <br />IT <br />'D <br />State <br />■ 7 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned properly or business owner, operator or authorized agent of same, acknowledge that all site and/or project1 <br />specific ENVIRONMENTAL HEALTH OEPARTMEN F hourly charges associated with this project or activity will be billed to me or my business as identified on 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 />APPLICANT'S SIGNATURE: <br />Type of Service <br />Requested <br />Comments <br />Phone Email . , ‘ {J <br />H i S S7</ / 7 61H") H1 / <A 2 WO <br /> Facility Owner <br />□•Application for <br />Operating Permit <br />; or License Plate I'Jumbcr VlN <br />Date . PE <br />last nam>e <br />Address <br />I <br /> OPERATOR/MANAGER <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator ol the property located at the above site address, hereby authorize the <br />release of any and all results, geotechnical data and/or environrnenlal/slte assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />n Record Number « <br />State: jla <br />Paying <br />If contractor, indicate type anAlixense number <br />...... project ”WI r <br /> Billing Parts I Facility OwnerI I <br />Application Form <br />□CfkAoi M cIiL I)v i <br />M l... <br />Supervisor District