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1$ New Facility Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name ZIPCity ^2$^ Other Change of Owner Repairs or Remodel Consultation VIN Architect Property Owner Contractor Facility Contact Facility Owner Billing Party ^Facility Owner ^4 Facility Contact ArchitectBilling Party Property Owner Contractor If contractor, indicate type and license numberFirst Name ZIPStateAddress Phom Contractor Architect Facility Contact Facility Owner Billing Party If contractor, indicate type and license numberLast nameFirst Name ZIPCityStateAddress EmailPhonePhone Contractor Property Owner Facility Contact Facility Owner Billing Party Last nameFirst Name City StateAddress EmailPhonePhone DATE: OTHER AUTHORIZED AGENT OPERATOR / MANAGER PROPERTY / BUSINESS OWNER Title Linked FA IDAccepted By If mobile food truck or pumper truck Contact Types required Application for Operating Permit 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. Record Number Type of Service Requested Comments Pion Rexjievj fey MFT License Plate Number Valley Supervisor District Assigned To VidaA P- Date . .(D3| IS 12^*4 Site Address ibTn APN uy , . State W) yd. Phone Email t Property Owner Last name , Jeff C. -?A S1Z..Z5D OsKp. Tz; 1077 Fee , Architect ----------------------If contractor, indicate type anHJicelst Aflfaer ____ BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all ^^^Sil^roj^’ct specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identiffiSfi^this form. I also certify that I have prepared this apelication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL law^-p^ ) / i C, I Q Q APPLICANT'S SIGNATURE:_^^^\Z?LZr?^r^'''^ DATE: [ [ -------------------------