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E New Facility □ Existing Facility San Joaquin County Environmental Health Department Application Form Supervisor District □ Other□ Repairs or Remodel□ Change of Owner□ Consultation VIN □ Contractor□ Property Owner□ Facility Contact□ Billing Party □ Facility Owner □ Contractor0 Property Owner□ Facility Contact□ Facility Owner□ Billing Party □ Architect□ Contractor□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party Phone □ Architect□ Contractor□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party If contractor, indicate type and license number ZIP Phone cshqa.com irmei DATE: lOPERTY / BUSINESS OWNER Title Linked FA IDAssigned ToAccepted By □ Check # Rev 07/10/2024 Contact Types required If mobile food truck or pumper truck Email roger@ecs-corp.net Last name Krieger City Boise City Manteca ZIP 94577 Payment Received By Email jim@efainc.com Last name Ashton Last name Graham Email paul.graham@ City San Leandro City Concord ZIP 95337 Phone 720-925-5508 //- □ OPERATOR/MANAGER State CA State CA State ID Phone (925) 969-9245 A □ OTHER AUTHORIZED AGENT ^Confirmation # First Name Roger Address 1200 Concord Ave, Ste. 200 Phone 510-773-7430 First Name Paul Address Type of Service Requested Comments First Name Jim Address 1066 Beecher St. Phone 510-430-8404 Facility Name Food 4 Less Site Address 2301 W Atherton Dr. APN If contractor, indicate type and license number B- 82540 State CA . /M/ 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 wo^/to be Standards, STATE and FEDERAL laws, APPLICANT'S SIGNATURE: * A ' □ Application for Operating Permit License Plate Number • 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. Fee , _________ Record Number , _ ■ac>3/W^7 2.03 Date . I □ Cash 05 If contractor, indicate type 94520 [II be done in accordance with all SAN JOAfZUIN COUNTY Ordinance Codes, y