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New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />^52 I 7£ <br /> Consultation Change of Owner Repairs or Remodel Other <br />VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />State <br />a <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />City State ZIPAddress <br />EmailPhonePhone <br /> Contractor Architect Property Owner Billing Party Facility Owner Facility Contact <br />If contractor, indicate type and license numberFirst Name Last name <br />State ZIPCityAddress <br />EmailPhonePhone <br />it <br />DATE: <br /> OTHER AUTHORIZED AGENT OR/MANAGER OPEI PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAssigned ToAccepted By <br />FeeDate <br /> Check Cash <br />Rev 07/10/2024 <br />Contact Types <br />required <br />iroperty or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />kirly charges associated with this project or activity will be billed to me or my business as identified on this <br />BILLING ACKNOWLEDGEMENT: I, the undersignei <br />specific ENVIRONMENTAL HEALTH DEPARTMENT^ <br />form. <br />I also certify that I have prepared this application <br />Standards, STATE and FEDERAL laws. I <br />APPLICANT'S SIGNATURE: I <br />n. \ <br />Email <br />State <br />L- <br />Type of Service <br />Requested <br />Comments <br /> Application for <br />Operating Permit <br />{rude <br />If mobile food truck or <br />pumper truck <br />Firsp^; <br />\c dress' <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required MAY 1 i) 2026 <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 ENVIRONlMlHiTAlL.'HEAlUiM COUNTY <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.__________________________________ENV’lRONMENTAL <br />_________HFA! TH DEPARTMENT <br />______ <br />RecordNumberl^^o^o_ <br />Payment <br />Received By (AAy <br />lame <br />.ri-sT\nG---------------Z <br />Address i <br />^4-k \ V. \ J) o <\x_\ S <3 <br />Phone ~ Phone <br />work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />W / y- T7 A PAYMENT <br />' RECEIVED <br />tame <br />vOQ/ _________________ <br />^Confirmation <br />:PE <br />Facility Na me/"'A <br />SiteAddress4J3X. For4 D <br />APN Supervisor Dis <br />Application Form <br />Mi c I - S. <br />> Q v'XC . S "Oy <br />Supervisor District <br />License Plate Number