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New Facility Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name Site Address APN Consultation Change of Owner Repairs or Remodel Other License Plate Number VIN Billing Party Property Owner Contractor Architect Facility Owner Facility Contact Billing Party pracility Contact Facility Owner Property Owner Contractor Architect First Name If contractor, indicate type and license numberLast name Address . C<y^ Billing Party Facility Owner Property Owner Contractor Architect If contractor, indicate type and license numberFirst Name Last name Address City State ZIP Phone EmailPhone Contractor Facility Owner Facility Contact Property Owner Billing Party Last nameFirst Name StateAddressCity Phone Phone Email SAN JOAQUIN COUNTY Ordinance Codes,libation ai DATE: OTHER AUTHORIZED AGENT OPERATOR / MANAGER PROPERTY / BUSINESS OWNER Title PE Fee Check It Rev 07/10/2024 If mobile food truck or pumper truck Contact Types required 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 ENVIRONMEN1AL HEALIH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Application for Operating Permit State Type of Service Requested Comments Confirmation # di Are/?i.o Assigned To i v 17X State r.A thjjt the work to be performed will be done in accordance with ajl SAN JOAQU U / hi Supervisor District If contractor, indTc^^^^jrj^^nZriber '9 ?025 ______________________________________________________ -------- BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge thatWillgjfld/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepared this Standards, STATE and FEDERAUawTs^ APPLICANT'S SIGNATURE: ' /Vick. Ph°ne mP ztA Ik l> Facility Contact Linked FA ID __ A _ ___ -_______000 / 3 7 ^3 Record Number t 5Ra501101 Accepted 0a,e5p^5~ Cash