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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address City StateZIP <br /> V <br /> �� V\- P C as 0 <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 ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First N eLast name o If contractor,indicate type and license number <br /> �Y( <br /> Address City� State ZI <br /> Phon Phgne <br /> ❑Billing Party ❑Facility Owner ❑Facility Cor+ ct ❑Pro e 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 ❑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 prepared t pIicatio nd that the work to be performed will be done in accordance with all SAN JOAQUIN C NTY Ordinance Codes, <br /> Standards,STATE and FEDERAL la n / w <br /> APPLICANT'S SIGNATURE: DATE: o� v �I�`' 1" <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 CO���f <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site add erebyaltari <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRQI_I-IEALf�//(( <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. h J9 SNC <br /> Accepted By Assigned To Linked FA ID TM <br /> Vial P �ranciSc.o � FAmmmm3�5 FNr <br /> DatePE Fee Record Number <br /> CpZ�lm�2m25 kU(2) 54225mm8�4L} <br /> Payment <br /> ❑Cash YAeck# O ❑Confirmation# Received By <br /> Rev 07/10/2024 wol 0q <br /> 3q <br />