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□ Existing Facility San Joaquin County Environmental Health Department Facility Name Site Address State ZIP 5-^03 APN □ Consultation □ Change of Owner □ Repairs or Remodel □ Other License Plate Number VIN‘j 32‘Has □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect X Facility Owner□ Billing Party □ Facility Contact □ Property Owner □ Contractor □ Architect If contractor, indicate type and license number □ Property Owner □ Contractor□ Billing Party □ Facility Owner □ Facility Contact □ Architect If contractor, indicate type and license numberFirst Name Last name Address City State ZIP Phone EmailPhone □ Facility Contact □ Property Owner □ Contractor □ Architect□ Billing Party □ Facility Owner If contractor, indicate type and license numberFirst Name Last name Address City State ZIP Phone EmailPhone DATE: PROPERTY / BUSINESS OWNER □ OTHER AUTHORIZED AGENT□ OPERATOR/MANAGER 2026 Linked FA IDAssigned ToAccepted By i^l □ Cash □ Check fl PMiowsoRev 07/10/2024 Contact Types required If mobile food truck or pumper truck If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required 2/1 AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMEWJAt DEPARTMENT as soon as it Is available and at the same time It is provided to me or my representative. ^Application for Operating Permit Phone Date -2^ Type of Service Requested Comments PE 730 re Supervisor District Qi*//I er Title :(VCode5,;-T|W_ JD Application Form S/V/? sh hqrCjers \ 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 OrdinancqfCodeS, ■ Standards, STATE and FEDERAL / Ozo O APPLICANT’S SIGNATURE: DATE: 7/ Q£ ■ , JUN 2 g New Facility FeeJ37c th all SAN JOAQUIN COUNTY O ® Confirmation fl Email x-v Z'P^^ Firs,Name5/>?r^Last name . ^^93 £<h&uJ6jte/J Coast Phone