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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facili gleam ku — - <br /> e Address �`�� � City Stag ZIP <br /> dl <br /> APN Supervisor District <br /> IWn <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 C <br /> Contact Types ❑Billing Party l Facility Owner Q Facility Contact El Property Owner Q Contractor Q Architect <br /> required <br /> K Billing Party IA Facility Owner 3?Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> st Name� Last ameh_ If contractor,Indicate type and license number�Se <br /> Address Ciyy State ZIP <br /> Call C 2 Lf D <br /> Phone Phone Email <br /> ICI- q `ou u,.' . ,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 Q facility Contact ❑Property Owner ❑Contractor�� �i7Gt <br /> First Name Last name If contractor,* dicate type number <br /> Address City StatSAN � V 4V25 <br /> Phone Phone Email �rH Ep 00Nry <br /> 0 <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all sit and/or project <br /> specific ENVtRONMENTAL 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 this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL la ii <br /> APPLICANT'S SIGNATURE: i]L� T.► DATE; <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 <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the above site address,hereby authorize the <br /> release of any and all results,geatechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENTas soon as It is available and at the same time it Is provided to me or my representative. <br /> Accepted B Assigned To Linked FA 1❑ <br /> Dat I Z PE � � 6 Fee d Numb <br /> n , ,l �� Payment <br /> El Cash ❑Check# onfirmation# 'J�,I1'u Received By <br /> Rev{)7/10/2024 �� �S� ���� <br />