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❑ New Facility ❑ Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name �" qu;v SALES Site Address City State ZIP 95�US 8��S L. ►QE yH o v> -si S7v Cie i a4 APN Supervisor District /1/ i/ Z z3 v Type of Service Cl Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other Requested Operating Permit Comments If mobile food truck or License Plate Number VIN pumper truck Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect required illing Party ❑Facility Owner ❑Facility Contact ❑Property Owner Ltl Contractor ❑Architect First Name Last name If contractor,indicate type and license number ®� Ar.✓C--� ATc,9S --c ,lac L. Address City State ZIP /0 7 4 0,�,) C P,4 L-w► 14 ve ymo-bE'"S'e Phone Phone Email 4c,7.S Z zz 1 �--7-2,�a.N.9��c�` o E,¢��/1S. r—© ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect First Name Last name If contractor,indicate type and license number Address City State ZIP Phone Phone Email ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect First Name Last name If contractor,indicate type and license number Address City State ZIP Phone Phone Email 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 and that th o to be performed will be done in accordance with all SAN JOAQUIN COUNT finance Codes, Standards,STATE and FEDERAL laws. /� j►��J APPLICANT'S SIGNATURE: ✓ ` DATE: s/� 9/,�S �[6-'.-. ❑PROPERTY/BUSINESS OWNER ❑OPERAT R/MANAGER IXOTHER AUTHORIZED AGENT '�� Title F �O ?9 O If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required y .q AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above eby� ize the release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY IQ�I HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. (/ Accepted By n Assign d To Linked FA ID JY 11�t.,, _1 Date FE Fee Record Number Or SR2SG) 1141 Payment ❑Cash Check# lyConfirmation# �� $2 �q Received By Rev 07/10/2024