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San Joaquin County Environmental Health Department <br /> Application_Form <br /> Facility—{N-a e <br /> r Pid2L�E <br /> Site Address City St 21P � 2 m <br /> X o'`C./ <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 <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> )M Billing Party Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> K First Name- Last me If contractor,indicate type and license number <br /> j <br /> h 27U <br /> Addres City State ZIP <br /> Phone Phone Email <br /> p 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 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 all AN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL law . <br /> X APPLICANT'S SIGNATURE: GATE: , <br /> —717 <br /> PROPERTY/BU5INESS O ER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT �°Ay�y�N <br /> Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required CEIV <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,h }r u t h a ize <br /> release of any and all results,geotechnicaI data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONM•rE., 1AL If/O.TI is <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> QU <br /> Accepted By JQ f� C Assigned Ta C\C"K&;a M Linked FA ID m0-0 J 7y <br /> Date�5` I Z PE Fee Record Number <br /> 1 1 S9-24& -Y�- <br /> �1� 12139 49 <br /> pRzqo2 <br /> 31 s <br />