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?(2. ^2* @ Existing Facility New Facility Supervisor District Other Repairs or RemodelWChangeof Owner Consultation VINLicense Plate Number Architect Contractor Property Owner Facility Contact Facility Owner Billing Party Architect Contractor Property Owner Facility ContactFacility Owner Billing Party If contractor, indicate type and license number Architect Contractor Property Owner Facility Contact Facility Owner Billing Party If contractor, indicate type and license numberLast nameFirst Name ZIPStateCityAddress EmailPhone Contractor Property Owner Facility Contact Facility Owner Billing Party Last nameFirst Name StateCityAddress EmailPhonePhone DATE: OTHER AUTHORIZED AGENT Title Assigned To l_A<-\V<Aces Fee \^~ Check tt Cash Rev 07/10/2024 If mobile food truck or pumper truck Contact Types required BILLING ACKNOWLEDGEMENT: I, tl specific ENVIRONMENTAL HEALTH form. I also certify that I have prepared Standards, STATE and FEDERAL I; APPLICANT'S SIGNATURE: ____ Application for Operating Permit San Joaquin County Environmental Health Department Application Form Phone City Date Type of Service Requested Comments LCfr't AlO uu A1* Phone Address 2'72'77 Phone70^ 9m State c A 2S Statf A Accepted By PE Facility Name , 'vRac-i UiPg Ano CM'TS Site Address .tv lit* St________, APN Last name . iA City I Architect If contractor, mdicatey^^ncflielT^'^tyi 22 2025 " I, tH undersigned pic TH b iPARTMENT hJji d /hi application Jrji that the work to be performed will be done in accordance with al P L DATE: ^ROPERTY / BUSINESS OWNER' OPERATOR / MANAGER If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required -....hnri/P the AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at theabovei sitep‘‘'' * /J ' ’ release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMF NT Al HEAI DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.-------------------------------------------------------------------------------------------- ___ ,teWa50i4JJ ^Confirmation # Received By ____ "'cj _____________________________________ undersigned pioperty or business owner, operator or authorized agent of same, ackno^MW^t^^A/T^, < ’ jrly charges associated with this project or activity will be billed to me or my busine!rA^gdonthis ill SAN JOAQUIN COUNTY Ordinance Codes,