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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> • ( I -C) oU <br /> SiteAdd,ess city State ZIP q5 3�I <br /> o <br /> APN Supervisor District <br /> ®, <br /> Type of Service ❑Application for Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Cotm�ents n <br /> UOY�c �ZJS2.'J � —f SOt\ V Dvf <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner 'L�i Contractor ❑Architect <br /> Firs ame Last name If contractor,indicate type and license number <br /> Address ty State ZIP <br /> Le k s;�e e ,•r� �Go sQ-V A <br /> Phone Phone Email <br /> M -\Sb� A4\A\t\ - (�" �1�. ',-\ <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact 1A Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> T\ uK <br /> Addrg o I 'r �f Y��`f City ` State ZIP�� <br /> Phone one Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State <br /> Phone Phone Email CFA:�!-F;11111 <br /> v <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,ackno that all sife&9nd/o�r�p�roject <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me rr� as ident'i�h this <br /> form. 9�VI� /�/ �v <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 JOA H 'T Codes, <br /> Standards,STATE and FEDERAL s. r .q ,r <br /> APPLICANT'S SIGNATURE: i DATE: LJ(� agRTM Nr <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER *OTHER AUTHORIZED AGENT 0&-I*QA (-of -Q 1K <br /> Title - <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required ll VV <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 /> Accepted By / Assigned ToI- /! Linked FA ID <br /> Date._ III I � PE Fee � -`✓ � � Rec_ b r r <br /> Payment <br /> ❑Cash VCheck# I, ✓ ❑Confirmation# Received By <br /> Rev 07/10/2024 <br />