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0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect aryiLlIcs e NT rt CeIVED ZIP MAR 1 9 First Name Last name PAYmis If contractor, indicate type Address City State Phone Phone Email 2025 sAN JaA Em.,,..Quilv rev......... p BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that a ?itd-MonEtAgfr specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on form. I also certify that I have prepared this appIicafionjnd that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL la . opor,ANts SIGNATU IV DATE: ? 2-,,5 0 PROPERTY! BUSINESS OW ER D OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT Title If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. E New Facility IV/Existing Facility San Joaquin County Environmental Health Department Application Form lit PerilityzNarne IA 1--‘r ofY‘ c% C o T. C/N ..1.- k- Milfkitiress a 3- 30 -S0l Cc c1/4 A Cit l ate ZIP 15 1 , -- - a , APN Supervisor District Type of Service Requested 0 Application for Operating Permit 0 Consultation aZhange of Owner 0 Repairs or Remodel 0 Other Comments If mobile food truck or pumper truck ,1.111*-nie;rfate NurOet f 3‘,,-E5.&3 VIN Contact Types required 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect ,Bitting Party 11 MONVIAtifrierg Ert:itillityContaci 0 Property Owner 0 Contractor 0 Architect First Name Last name If contractor, indicate type and license number Address City k3- State C API , ZIP Phone SIO ' Lin Li 1 ..3 i Phone Email Otranct Con( C‘Sit"..c Q CO'l eNA k • ( CrV1 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email Accepted By i Shannon B. Assigned To c i cw di a m. Linked FA ID Date 3.1 9.a5 PE /002 Fee 4 17 Record Number aRa5009 3 4- 0 Cash 0 Check # AConfirmation # 12971) 2---232 Received B Payment B ' TR09-11-34- Rev Rev 07/10/2024