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❑ New Facility ❑ Existing Facility. <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address 00 City State ZIP <br /> Lr.i qS6`73 <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile Food truck or License Plate Number VIN <br /> pumper truck V 619 9 c qOs <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ®Property Owner ❑Contractor ❑Architect <br /> First Name Last name ! If contractor,indicate type and license number <br /> J o by-i 1 LA \ ar; ca <br /> Address 9City State Zip <br /> 100 �e-r\a LA cfs695 <br /> Phone hone Emai! <br /> o9y ��22z9`(3� Move �' a <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 0 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 billed to me or my business as identified on this <br /> form. �4 <br /> I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUN f67Y <br /> Standards,STATE and FEDERAL laws. �l <br /> APPLICANT'S SIGNATUR . DAT&- 4� �� 1 �s EcE1VEO <br /> F� <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT C <br /> Title AIv J �025 <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Ely/"QU/Iy C <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site ad �ef�� <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN)OAQUIN COUNTY ENVIRONME <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. kr <br /> Accepted By gscigned To ' Linked FA ID <br /> Dale?0( 2 5 PE 03 Fee 1 L l� 4M—SOr/&J& <br /> ❑Cash ❑Check# &i Confirmation# 1q�g806�L� Payment <br /> Received By <br /> Rev 07/10/2024 waiv3L-1 <br /> 5 <br />