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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address City State ZIP <br /> �e I OT-) eqL C4' r c C 4 5 377 <br /> APN Supervisor Distr <br /> Type of Service [94Mplication 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 /> ❑Billing Party ZlFacility Owner ❑Facility Contaa7 ❑Property Owner ❑Contractor ❑Architect <br /> First Name J Last name n,�ame If contractor,indicate type and license number <br /> Addr ss Ci State ZIP <br /> b Ct- CA `15Y77 <br /> Phone Pho4e Email <br /> f 5 '7 Ice e�1 iE-cu a s A e-f <br /> (Killing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor 0 Architect <br /> first Name Last name If contractor,indicate type and license number <br /> L le[uL} 1-', jU(� <br /> Address _ Cit State ZIP <br /> ('Plb fir} .k-t ra^'- C�- �qC C `r5 377 <br /> Phone Phone Email <br /> �&(- i5--rq C•)aW;e(IQ—Ctcr <br /> ❑Billing Party L]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 SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDE law ,'�APPLICANT's SIGNATURE: 'JX (� y <br /> DATE: <br /> ®PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title � N <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required ���!!t '''��_ <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the above site address,h aµthorize tTfFV <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIN MENT L E1�iLT9 <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> NCO <br /> Accepted By Assigned To Linked FA!D �dEZ ENV, <br /> Vy <br /> Date PE i U,V Fee Record ffurr>ke� 20 1 9$W r <br /> r!Wt"1 L V�:]❑Cash ❑Check tf "nfirmation k zo0 /.,/„2 Payment <br /> /J D Received By <br /> Rev 07/10/2024 v <br /> 2 ry-p13� <br />