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4 □ New Facility □ Existing Facility San Joaquin County Environmental Health Department Application Form Supervisor District □ Change of Owner□ Consultation □ Repairs or Remodel —--- Mobile □ Property Owner □ Contractor □ Architect□ Billing Party □ Facility Owner □ Facility Contact □ Facility Contact □ Property Owner □ Contractor □ Architect If contractor, indicate type and license number City State □ Architect□ Property Owner □ Contractor□ Facility Owner □ Facility Contact□ Billing Party First Name Last name ZIPCityStateAddress Phone EmailPhone □ Contractor□ Property Owner□ Facility Contact□ Billing Party □ Facility Owner TLast nameFirst Name ZIPCityStateAddress EmailPhonePhone DATE:04/14/2025 □ OTHER AUTHORIZED AGENT Q OPERATOR / MANAGER□ PROPERTY / BUSINESS OWNER Title Linked FA IDAssigned ToAccepted By □ Check tl□ Cash Rev 07/10/2024 Contact Types required If mobile food truck or pumper truck □ Facility Owner Genaro Silvestre □ Application for Operating Permit Email Genarosilvestre58@gm i Last name Silvestre VIN 18981CE21NG945014 ZIP 95220 ZIP 95220 □ Other Health permit Payment Received B' 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. City Acampo Phone 2096639840 State CA Date Record Number __APZ-SOISZ-G ~[~f 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: ^'confirmation it □ Billing Party Genaro Silvestre First Name Genaro________ Address 23090 N Kennefick Road___________ Phone 2096639840 Type of Service Requested Comments Facility Name ________Gen Spot______ Site Address 23090 N Kennefick Road APN Fee License Plate Number 4VF6444 1 pf If contractor, indicate type and licensF^flrKx1* * J____ If contractor, indicate type and license number "t'A