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PNew Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> acoS l Soc�c� <br /> e,A�ddress men f CitYLO�I Staten <br /> APP'N Supervisor District { <br /> Type of Service ❑Application for Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> 1f mobile food truck or License fla a Num r VIN11 <br /> f <br /> pumper truck � f t q ( 7 <br /> Contact Types ❑Billing party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party NFacility Owner Facility Contact ❑Property Owner ❑Contractor 7hitect <br /> First Nal Las a if contractor,indicate type and license number <br /> t mmn 'U$Zy(Iddress LiaKQ '�QrK 0Q_ LSO <br /> Phone Phone Email <br /> ol( SCCLC all 4,co m <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 ❑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: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 bltled to me or my business as identified on this <br /> form. <br /> I also certify that I have prepared this applica ' and that the work to be performed wilt be done In accordance with all SAN JOAOU3N COUNTY Ordinance Codes, <br /> Standards,STATF and FEDERAL laws. + /� / <br /> APPLICANT'S SIGNATURE: de.- DATE: 0 8"3 V^J0 0 r�'f <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHC l2EfJ AGENT A <br /> Title Re Y�E <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign i5 required rc 1 r <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authonz PI <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENAt�T <br /> ❑FPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> Accepted B Assigned To Linked FA ID H Ely(h1�0lIV�UJV <br /> sP-4 C rrct1AC;sCa R . Maw <br /> Date PE F Record Number QT ��1f <br /> ak-O4 Fee »z [ a . HPz a� <br /> �// �� Payment <br /> ©Cash ❑Check# L8'Confirmatlon# Received By <br /> Rev 07/10/2024 <br /> P9250013 U <br />