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□ Existing Facility□ New Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address <br />APN <br />Im Change of Owner□ Consultation □ Repairs or Remodel □ Other <br />License Plate Number VIN <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />[^Facility Owner S Facility Contact □ Property Owner □ Contractor □ Architect <br />If contractor, indicate type and license number <br />Address <br />□ Billing Party □ 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 EmailPhone <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address City State ZIP <br />Phone Phone Email <br />litafibn and that tl w<;o <br />□ OPERATOR/MANAGER <br />Title <br />Accepted By <br />Date <br />□ Cash □ Check ti <br />Rev 07/10/2024 <br />MEnt <br />JO <br />□ Application for <br />Operating Permit <br />If mobile food truck or <br />pumper truck <br />Type of Service <br />Requested <br />Comments <br />□ Facility Owner <br />Contact Types <br />required <br />f □’'Billing Party <br />RstNarn^ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT 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 a| <br />Standards, STATE and FEDERAL laws/ <br />APPLICANT'S SIGNATURE: Z <br />□'PROPERTY / BUSINESS OWNER / <br />Vicb-l P&dra <br />pe\(pOJ <br />Application Form <br />Supervisor District <br />Emai1 \ <br />performed will be done in accordance with all SAN JOAQUIN .COUNTY Ordinance Codes, <br />—_______ DATE: O / <br />□ OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required JIlKl n <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hjjrtby the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUISJjQbNyiRONMENTAL HtftLTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.______________________g COUNTV <br />FAOaegWr <br />Record Number <br />512.55013 33 <br />Assigned To __ /I <br />J 4rra■■ <br />M Confirmation ft