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W . <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> -t) coo do C e- <br /> Facility Name <br /> c- <br /> Site dress Cit. St e ZIP <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit r <br /> Comments <br /> If mobile food truck or License Plate Numb VIN <br /> pumper truck y1nD81ot <br /> Contact Types Billing Party 61 Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ElBilling Party ❑Facility Owner ❑Facility Contact::1❑Property Owner El Contractor ❑Architect <br /> First Las naame If contractor,indicate type and license number <br /> Address f ., City St �'Sgn--3 <br /> P <br /> t--lJ , 4 alll <br /> 1 <br /> Pho Phone Email <br /> J� <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 Stat ZIP <br /> Phone Phone Email <br /> T <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner Cont t r ❑Archi e <br /> RECEIV D <br /> First Name Last name f co tra indicate type and license number� <br /> MIAY 2(24 <br /> Address City I fState ZIP <br /> SAN JOAQUIN CC�Nn' <br /> Phone Phone Email <br /> HEALTH DEPART AENT <br /> BILLING ACKNOWLEDGEMENT:I,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 and that the work to be performed will be done in accordance with II SAN JOA IN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> �L <br /> APPLICANT'S SIGNATURE: � � —�— DATE: <br /> ®PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <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 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 To ) ) � Linked FA ID � <br /> Lf r rJ F ✓l ( Y/ID'l <br /> Date PE Fee Rec tuber <br /> 7J-1163 0 4 q9 g2qt Z� <br /> VISA -it! bl T L%3 <br />