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❑ New Facility Cj/Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name A <br /> rros e-1/aC Z <br /> Site Address City State ZIP <br /> APN Supervisor District <br /> Type of Service ❑Application for onsultation ❑Change of Owner Lf Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments iE4C 1v <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types .__L❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Q Billing P rt ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Las�.tsame f If contractor,indicate type and license number <br /> �'j6k -e _ <br /> Address I S S S 4 .[L'b StateC A ZIPFc� <br /> hone Phone Email aj <br /> -30 <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Andress City State ZIP <br /> Phone Phone Email —1 <br /> 17 Btliing Party ❑Facility Owner ❑Facility Contact F"y Owner Q Contractor ❑Ar t�az. <br /> �V <br /> First Name Last name If contractor,indicate type and lic YE <br /> Address City State $q ZI 4 <br /> Phone Phone Email N N�WO lIVG+�U <br /> r ��E Hrr <br /> BILLING ACKNOWLEDGEMENT:1,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or pr ]' <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 application and t at 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: �/ 6 <br /> Y <br /> DATE: `f •�f`' <br /> ❑PROPERTY/BUSYNESS OWNER ❑OPERATOR/MANAGER Cl OTHER AUTHORIZED AGENT <br /> Title <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 of the property located at the above site address,hereby authorize the <br /> release of any and all results,geotechnical data and/or environmental/site 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 /> Accepted By l Assigned To r y<, f� Linked FA ID <br /> Date 4 n PE r12 Fee# Recpfdpk}11PO n ['4LA <br /> v �� ��.J �� Payment <br /> ❑Cash ❑Check P Confirmation d Received Fly <br /> Rev 07/10/2024 <br />