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❑ New Facility A Existing Facility <br /> San Joaquin County Environmental Health Department <br /> _ Application Form <br /> Facility Name - <br /> z 2r7, 5 I C?C 7r 1. e A L i'Zza f' <br /> Site Address td - -2 1 .0 <br /> City State ZIP <br /> APN Supervisor District <br /> 7mob� <br /> APpllcation for ❑Consultation ❑Change of Owner ❑Repairs or Remodel Q Other <br /> Operatfng Permit <br /> Ci <br /> qe <br /> truck or License Plate Number VEN <br /> C antact Types ❑Billing Party ❑Facility Owner acity .Contact ll Property Ow <br /> liner ©contractor Architect <br /> required <br /> Billing Party XFacillty Owner rKacllltyCOntact ❑Property 0wner ❑Contractor ❑Architect <br /> Firs Name Last name If contractor,indicate type and license number <br /> Address City _ State 7JP <br /> ��l �Ir` ULQ� aft IZ ca�- <br /> Phone Phone Email <br /> 00 �!Sr✓�Sr Trl ! b d 9, { 2,[ �YrAri •Ct9'Y+�1 <br /> ❑Billing Party ❑Facility Owner acility Contact ❑Property Owner ❑Contractor ❑Architect <br /> Firs Nam Last name If contractor,Indicate type and license number <br /> G adA <br /> Address City state ZIP <br /> nm�9r' �•atnr��. _ ;e 4C(m1 <br /> Phone Phone <br /> q+�. Y <br /> dLWz <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner �lf <br /> Contractor �type <br /> Architect <br /> First Name East name ontractor,Indicnd license n <br /> Address City State Zip tN <br /> Phone Phone Email V&O <br /> 024 <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all sJt a� ��Q] tM r� 7- <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this protect er activity will be billed to me or m business as identr <br /> form. A11 �Nr 1 also certify that I have prepared this application and jha the work to be.performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. �y <br /> APPLICANT'S SIGNATURE: DATE: t�a <br /> ❑PROPERTY/BUSINESS OWNER OPERATOR/MANAGEROTNER ALITHORI2EU AGENT y\ <br /> rf APPLICANT Is not the BILLING PARTY,proof of authorization to slgn is required Title <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,geotechnlcal data and/or envlronmental/site assessment Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL tiEALTII <br /> DEPARTMENT as soon as it is available and at the same time it is provided tome army representative. <br /> Accepted By Assigned To Linked FA i0 <br /> Nick Wieseman °�rd1i��u7. <br /> Date 10-16-24 PE 1602 Fee 172 htiF�V <br /> Rev66/12/ZO24 Payment 189523395 <br />