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rs( New Facility • Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name T\..\ £.. C 1-\At-'H.=\..,~()N \Vl;;-n-\ 0 D <br />Site Address 3"1-W 'I o~v,·s Av -5U,TE G'"" City State ZIP S,QCK.,ot--1 c:....~ Qt;'l.O'i- <br />APN Supervisor District <br />I <br />Type of Service D Application for lli:l'Consultation D Change of Owner D Repairs or Remodel • Other <br />Requested Operating Permit <br />Comments <br />If mobile food truck or License Plate Number VIN <br />pumper truck <br />• Billing Party • Facility Owner D Facility Contact D Property Owner • Contractor • Architect <br />Billing Party Facility Owner Facility Contact D Property Owner • Contractor D Architect <br />First Name <br />HA~l 'H <br />Last name <br />Nf\ <br />If contractor, indicate type and license number <br />Address <br />f\S\-\WOOD U\Nl:.- <br />State ZIP <br />tf\ <br />• Billing Party I D 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 I Phone Email <br />• Billing Party D Facility Owner D Facility Contact D Property Owner D Contractor <br />First Name Last name If contractor, indica <br />Address City State <br />Phone Phone Email <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge tlia /or project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as i e i\l~d on this <br />form . <br />I also certify that I have prepared this appl' a · ark to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: ---+-4-~1,.£.....i.:.it..::....t:..-=...L.....::..:::...:.__=. _______ DATE: _.(_,l+f-'1'--'8-'+l---''.2; .. r--... 2'-------- <br />✓i,ROPERTY / BUSINESS OWNER OPERATOR/ MANAGER • OTHER AUTHORIZED AGENT Q W N£.lZ. ~~~~~------- <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 environmenta l/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is avai lable and at the same time it is provided to me or my representative. <br />Accepted By Assigned To Linked FA ID <br />Date PE <br />It zs/z<:J '-t 10 ::> <br />Rev 06/12/2024