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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address yn L, ` City a Stat� <br /> APN Supervisor District <br /> Type of Service E19kpplication for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments 4 <br /> /(�eco C FG Criss <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> filling Party Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> Fi Name ame If contractor,indicate type and license number <br /> Address eadcW Y-c�-y'/ Ci- rap,) <br /> State ZIP <br /> P e //-- Phone EE`mail CJ� ' <br /> yid 1-0 OCo t co <br /> ❑Billing Party ❑Facility Owner ❑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 <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner I-]Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <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 project or activity will be billed to me or my business as identified on this <br /> form. <br /> I also certify that I have pre?5140 this a lication and a work to be performed will be done in accordance with all SAN JO QUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FED RAL <br /> APPLICANT'S SIGNATURE: V`--Q�4 DATE: �^Y <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required V,1� <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address authoris?e ? <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENV IRON <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. OJT► —W <br /> Accepted By,J of lP C Assigned To m �' L' d FA ID ��n <br /> �rn1 � 1 1 rnL� L� �1 !Y� �!?i <br /> Date`- !wl '1 PE I�W lJ Fee ` � din R cP2—T Z5J1 <br /> v� �cci,?ai d ol m d-c <br /> �� #4 41 $ 3 <br />