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□ New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address ZIP <br />96 2.0 6 <br />APN <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />License Plate Number VIN2^02-0^ <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />Facility Owner□ Billing Party □ Facility Contact □ Property Owner □ Contractor □ Architect <br />Last name <br />Address <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address City State <br />Phone Phone Email <br />o□ Facility Contact □ Property Owner□ Billing Party □ Facility Owner <br />First Name Last name <br />Address City State <br />Phone Phone Email <br />□ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGER <br />Title <br />Accepted By <br />U P~C> <br />Date PE 1403 <br />□ Check tt□ Cash <br />Rev 07/10/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />□ Application for <br />Operating Permit <br />Payment <br />Received By <br />ZIP <br />362IO <br />Phone <br />^PROPERTY / BUSINESS OWNER <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 environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.> <br />/^Confirmation H <br />Type of Service <br />Requested <br />Comments <br />_____ Application Form <br />£ I Taras 11 o_____________ <br />2qoc> E F|arclmO| <br />Supervisor District <br />\|a<^as <br />Email <br />Assigned To <br />< /? <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 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 laws, ef ’ . r '“i < O O O /"APPLICANT'S SIGNATURE: /'A D ' \J DATE: Q Z-- I - Z O <br />If contractor, indicate type and license number <br />State . <br />CQlil-CKnifXs\ock4(X\ <br />unkedTAQ(W5qq <br />Record Number <br />5RaCpQIS74 <br />□ Contractor!^ M Architects^ <br />If contractol^jfiyjc^jJl^i^d licenCflnumber <br />------------------ <br />Q , m Ll <br />First Name s- <br />5e< QpQ_______ <br />Scir\ pasqpQ <br />Phone