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New Facility □ Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name City Leoi APN □ Consultation □ Change of Owner □ Repairs or Remodel □ Other □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect ^Property Owner'^facility Owner '^Facility Contact'^Billing Party □ Contractor □ Architect If contractor, indicate type and license numberLast name Address State ZIP C Phone □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect First Name If contractor, indicate type and license numberLast name Address City State ZIP Phone Phone Email □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor First Name Last name Address City State Phone Phone Email . DATE: □ PROPERTY / BUSINESS OWN □ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGER Title Linked FA IDAccepted By Assigned To Fee □ Confirmation ft 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. If mobile food truck or pumper truck Contact Types required Email VIN Type of Service Requested Comments Date - • ''''rfcash Rev 07/10/2024 ZIP Site Address — Supervisor District First Name^—v . ..w..v Phone □ Billing Party If contractor, indicate/T^oe and lict/ifj^£unDcr ----------- ZIP wo 'fa Application for Operating Permit License Plate Number . < —. ^03^^ State f A BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/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 application ancLthat thq,work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. 7 V "7 // / 7 y < APPLICANT'S SIGNATURE: , DATE: / / /Zo/ □ Checks Record Number Payment T'7 ~ Received B\»