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City t 00-67(00 )-4C0--- Supervisor District Site Address APN State ZIP 152j3S— Type of Service Requested 0 Application for Operating Permit 0 Consultation Change of Owner 0 Repairs or Remodel 0 Other Facility Name po 5 a. 3 QA (7e. Comments If mobile food truck or pumper truck License Plate Number VIN Billing Party I;g Facility Owner AFacility Contact 0 Property Owner 0 Contractor 0 Architect First Name I-1 40i L PAA Last name Af Address ?q4 cZ5.Xzl A-ub hone c‘ 0 Phone Emati Cz Art aLLAC4 S V If contractor, indicate type and license number State ZIP Oita- e. 6- • iv \ cz-A- City e vac AA-z. 1 ci53 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 COntractor 0 Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email n If 47), BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all sith'gRity tct specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified 41Whir form. I also certify that I have prepared this ap.lic. • and let the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, _a Standards, STATE and FEDERAL laws.___________ APPLICANT'S SIGNATURE: As"— 41111116 DATE: 2 / to/?.-(( 0 PROPERTY / BUSINESS OWNER 0 OPERAT / MANAGER LI OTHER AUTHORIZED AGENT Title If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. 0 New Facility Existing Facility San Joaquin County Environmental Health Department Application Form Contact Types required 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect P4V ' I CCE71; IF r zDeps vt;• First Name Last name If contractor, indicate type Address City State Phone Phone Email Am•ENV/z, J0,4 202 4 QUM/ r ,— Accepted By \II6C\ P. Assigned To L. \ auc\-kc\ M Linked FA ID Date PE Fee . Record Number 0 Cash ,heck # /453— 0 Confirmation # Payment Received By Rev 07/10/2024 PRoapait