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C] New Facility Existing Facility (needs SR#) San Joaquin County Environmental Health Department Application Form Facility Name A r` 0 Site Address 7 ` ' City t State ZIP I ? qV" N o APN Supervisor District a(01- 0 - 1k Type of Service ❑Application for ❑ Consultation ❑Change of Owner epairs or Remodel ❑Other Requested Operating Permit Comments / ', / �p h `.y 7-0 Y-P r `QC� f r^ C' l r�� /�(�� t') n'$S Y�CLt ✓c. `� t4a4 Del 'NJCr, Cur/ti c� (r e iJ) (�►ye.rt, If mobile food truck or License Plate Number VIN Y pumper truck Contact Types Rd Billing Party ❑ Facility Owner IN Facility Contact ❑ Property Owner ®Contractor ® Requester required 14ZBilling Party Facility Owner ❑ Facility Contact , ❑ Property Owner G77weetor ❑Architect e �t.v f7, First Name P� �j_ Last name If contractor,indicate type and license number '1 Address City�t O � State � ZIF+ Phone Phone Email Zoq 59S'- w60o IS.Y-C,, •J- a 1� k . cv PL'q ❑ 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 II`♦`�� Address City State ZIPSD Phone Phone Email h��rhR4N/N BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or projec 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 the work to beperformed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards,STATE and FEDERAL laws. APPLICANT'S SIGNATURE: 1� L! L DATE: PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT e'F Title 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 tome or my representative. Accepted By n Assigned To Linked FA ID Date„ I 2 PE �� Fee ec Record Number ❑ Cash ❑ Check N Confirmation It Payment Received By Rev 07/10/2024 2 of 6