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❑ New Facility Y Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name CjD m L <br /> W V[ r, 5 <br /> Site Address,� -: , Y v t t�y. �\-L. �• y State) Z� <br /> APN ll y T 1 S1upe visor District lye/ <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 ❑Facillty Owner ❑Facillty Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> 611iing Party Facillty Owner -fJ Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last r� ��Nu If contractor,indicate type and license number <br /> 4a <br /> Address � p� ) y Stat Z# <br /> Phone Phone Email <br /> ❑Billing Party ❑FaciPty Owner ❑Facility Contact El 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 /> I7 80ing 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 t have prepared this a plic n and that the work to be performed will be done in accordance with alllSAN JOAQUIN COUNTY Ordinance <br /> Codes, <br /> Standards,STATE and <br /> APPLiCANrs SIGNATURE: la s. DATE: l �O 0—F?' • � <br /> ❑PROPERTY/BUSINESS OWNER OPE OR/MANAGER ❑OTHER AUTHORIZED AGENT vie-It <br /> Title & 9 <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 addr�� authori <br /> release of any and all results,geotechnical data and/or environmental/sRe assessment information to the SAN JOAQUM COUNTY ENV !� H <br /> DEPARTMENT as soon as It Is available and at the same time it is provided to me or my representative. <br /> C] �N ��Ll <br /> a <br /> Accepted By Assigned To Linked FA ID ANT <br /> Vicki P. rranctac.c) R� F,4001 449m <br /> Date PE Fee Record Number <br /> Payment <br /> ❑Cash ❑Check q Iff Confirmation q r , ( Q <br /> `i �`T `� Received By <br /> Rev 07/10/2024 <br /> P�p52�vZ� <br />