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❑ New Facility A Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facilit Name <br /> El f c(AT nc 1 es u�rlip <br /> Site Add s City State <br /> o .k-Fvn c lc�v <br /> Al Supervisor District <br /> Type of Service ❑Application for ❑Consultation Change of Owner I1 Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <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 /> fl,Billing Party Facility Owner Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name if contractor,indicate type and license number <br /> 'AV-ku il CQonzr k-C 2- <br /> ddress City State ZIP <br /> in(v O Nruaw vtAIke- oq i s 1 ,nC Pr al <br /> Phone Phone Email aim PI�Z�CAUS <br /> qLA LA-Z S <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 ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact C7 Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> BILLING ACKNOWLEDGEMENT:1,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 a t the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws, P APPLICANT'S SIGNATURE: DATE: Nell <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT ECE�VE <br /> Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required fig, 1] 9n! <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address 0&A �h�ouu z the <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIR �t+�1GQUM <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative, �rhl —- TAI <br /> Accepted By Assigned To Linked FA ID <br /> CXalnc;ts c v R• f=A®�Dm 259� <br /> Date PE Fee �ord Number <br /> Tgillq2� t(o1 2,-(Z� Z'gft� 3G <br /> ❑Check li Payment <br /> ❑Cash <br /> confirmation q �' � Received By <br /> Rev 07/10/2024 <br />