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P New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Fa c'Ity Name <br /> V)C n Y`P <br /> �,. Site Address-) 5tateC <br /> APN Supervis District <br /> Type of Service Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> Qtrw MfF (Qycv,4i�s1.� Yrc�iSter ed ,fN Mercrcl <br /> If mobile food truck or L tense Plate Number VIN <br /> pumper truck i 5 Qj <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact 0 Property Owner Q Contractor ❑Architect <br /> required <br /> PO Billing Party 91 Facility Owner 54 Facility Contact L1 Property Owner 0 Contractor ❑Architect <br /> F' st Name Last name If contractor,indicate type and license number <br /> Sa — k vn <br /> Ad ress LJ <br /> P Stat ZIP�/�+�7 <br /> t. 117 <br /> P one q r}I- Phone i Email <br /> ❑Billing Party L7 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 pAYMENT <br /> ❑Billing Party f]Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ect <br /> First Name Last name If contractor,Indicate type an s b r <br /> Address City State <br /> IWI pEPARTMEN <br /> Phone Phone Email <br /> BILLING ACKNOWLEDGEMENT:I,the urdersigred property or business owner,operator or authorized agent of same,acknowledge that ail site and/or project <br /> specif{c ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this protect 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 ation nci that t be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERA 5, <br /> APPLICANT'S SIGNATURE: DATE: /�I ZOZtI <br /> ❑PROPERTY/BUSINESS NER ❑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,gectechnical data and/or environmental/site assessment Information to the SAN 1OAQUIN 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 /> :Te4 L1 s C)t F. <br /> Date PE Fee Record Number <br /> ��:;�slz�t It:�� �>,�z .tvm APLyQ�mB'3Q7 <br /> 1 S Q� Payment <br /> # El Cash ❑Check Confirmation# f�] Received By <br /> Rev 07/10/2024 �/j7 <br /> 2 �I 0 <br />