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K Existing Facility□ New Facility San Joaquin County Environmental Health Department Facility Name Site Address StateCity ZIPGA APN □ Consultation 54'Change of Owner □ Repairs or Remodel □ Other License Plate Number VIN □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect Billing Party £3 Facility Owner JkT Facility Contact □ Property Owner □ Contractor □ Architect First Name If contractor, indicate type and license numberLast name Address State ZIPcA Phone Phone □ Billing Party □ Facility Owner □ Property Owner □ Contractor □ Architect First Name If contractor, indicate type and license numberLast name Address City State ZIP Phone Phone Email □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect First Name If contractor, indicate type and license numberLast name Address City State ZIP Phone Phone Email DATE: □ PROPERTY/ BUSINESS OWNER □ OPERATOR/MANAGER □ OTHER AUTHORIZED AGENT W2□ Cash □ Check il Rev 07/10/2024 Contact Types required If mobile food truck or pumper truck □ Application for Operating Permit Payment Received By BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this applic^U Standards, STATE and FEDERAL laws. XJ APPLICANT'S SIGNATURE: Accepted By JeFf C. [3 Confirmation tt Type of Service Requested Comments Phone' ________ Linked FA ID FA(^0(b3>(Ll-7 Record Number SR25<2)(H(7) that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, GepG Title PE \^(bZ c nwuUmaX City A Assigned To Kadeane L. Fee $112.00 Email y \ S- □ Facility Contact Application Form 30, ^00 yA Supervisor District 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, hereJjMaupiorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAVWX^H^ DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. ----------------------^5 Date . .051ZA125