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C New Facility njxisting Facility <br /> San Joaquin County Environmental Health Department <br /> Ap ication Form <br /> Facility Na rc no s TroNy4ti 42. <br /> Site Address 1 <br /> " City State ZIP <br /> CQ' I y i C cis <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner C3 Facility Contact ❑Property owner ❑Contractor ❑Architect <br /> required <br /> lling Party t94acility Owner Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> Fir ame Last name If contractor,indicate type and license number <br /> Address � � � C' ` � StateC � ZIP � ^ <br /> one Phone Email <br /> ❑Billing Party ❑Facility Owner El 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 Phone Email p�r <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor Alt t <br /> First Name Last name If co ridicate type AwInse number <br /> t 'aQU! <br /> Address City Sta TN Dip E �r <br /> A <br /> AAL <br /> Phone Phone Emai} r <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 projector 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 that the work to be perfor will be done in accordance with all SAN JOAQUIN UNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. �r ✓ t <br /> APPLICANT'S SIGNATURE: b (�'4 r fi f SJ Je DATE: © Q 6— <br /> A ROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT (k) V1 �' r <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 Assigned To CWV9711 <br /> Date � 2Z PE Fee o J <br /> Cash Payment <br /> 0 Check q ❑Confirmation it <br /> Received By <br /> Rev 07/10/2024 � � <br />