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San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />S'Ip Adders^ZIPStateCHy\)‘\csV>Io Av't CM <br />APN <br />' j Othnr[1 Pfp.nr', or RemodelVTChanf’e of Owner□ Consultation <br />license Plate Number <br /> <br />VINor <br />Property Owner □ Architect□ Contractor□ Billing Party □ Facility Contact□ Facility Owner <br /> 1 <br />p/Property Owner□ Billing Party □ Architect□ Facility Owner □ Facility Contact □ Contractor <br />If contractor, indicate type and license numberLast name <br />State <br />Email <br />□ Contractor □ Architect□ Property Owner□ Billing Party □ Facility Owner □ Facility Contact <br />If contractor, indicate type and license numberLast nameFirst Name <br />City State ZIPAddress <br />EmailPhonePhone <br />□ Contractor □ Architect□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party <br />Last nameFirst Name <br />StateCityAddress <br />EmailPhonePhone <br />DATE: <br />□ OTHER AUTHORIZED AGENT ’PROPERTY / BUSINESS OWNER <br />Title <br />Assigned To <br />Fee <br />1^2° <br />I Supervisor District <br />City < <br />if mobile food truck <br />pumper truck <br />(1 Application for <br />Operating Permit <br />Contact Types <br />required <br />c B 2-31 PW>SI5SIS <br /> _ ■ . —■rBlUIIIWI-. •L-TT-T— r <br />i PhoneI <' <br />j First Name <br />i__ <br />, Address <br />Type of Service <br />Requested <br />Comments <br />MdB Pi 2-^ <br />p^s^ <y <br />ne . , . PhonelAlu) -DWh <br />______________________________ _ ________ - - <br />~BirLlNG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledjp^^^QWtt^J^p^mject <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me orHg^i^flWMgi^ijWsr <br />I also certify that I have prepared this appljc^tion and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordina! <br />Standards, STATE and FEDERAL laws. nAT|:. 5 ' 'tO l_£ <br />APPLICANT'S SIGNATURE: . ------ <br />□ OPERATOR/MANAGER <br />ZI?C5\^5^ <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 environmcntal/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 /> I <br /> <br />4i=Hj <br />If contractor, indicate typeaad license number <br />JUNTYoSmM^rdes, <br />lAcceptedB, <br />igWbrjw