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0° <br /> Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />StateSite Address <br />Supervisor District <br /> Other Repairs or Remodel Consultation Change of Owner <br /> Architect Property Owner Contractor Facility Contact Facility Owner Billing Party <br /> Architect ContractorST Facility Owner Property Owner Facility Contact Billing Party <br />If contractor, indicate type and license number <br /> Contractor Architect Property Owner Facility Owner Billing Party <br />If contractor. Indicate type and license numberLast nameFirst Name <br />State ZIPCityAddress <br />EmailPhonePhone <br /> Architect Contractor Property Owner Facility Contact Facility Owner Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />ZIPStateCityAddress <br />EmailPhonePhone <br /> OTHER AUTHORIZED AGENT <br />Title <br />Linked FA IDAssigned ToAccepted By <br />Fee <br /> Check U <br />Rev 07/10/2024 <br />W'Z.U’ODDS'I <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />PAYMEM <br />RECEIVE D <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br />form. <br />I also certify that I have prepared^thi: <br />Standards, STATE and FEDERAL, <br />APPLICANT'S SIGNATURE: <br />l( Trvo <br />APN ' ' ::T— <br />Stateo <br />Type of Service <br />Requested <br />Comments <br />Email <br /> Facility Contact <br />PE <br />First Name <br />Address <br />Phone I ■Phone <br />[^'Confirmation B <br />Pf^New Facility <br />Last name <br />Date/ I . <br /> Cash <br />[^Application for <br />Operating Permit <br />- H«5> O') <br />VIN <br />a/A <br />zip <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required ---L <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby-dilhoM th£(J4) <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. _____________SAN JOAQUIN COUNTY <br />environmental <br />HEALTH DEPARTMENT <br />ZIP ^^2.0^ <br />>ared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />-------------------------------------------- DATE: | (1^ <br />'PROPERTY / BUSINESS OWN^R ( □ OPERATOR / MANAGER <br />Record Number <br />A'PSl(s>Q3cI(j>7- <br />ng <br />Lkense Plate Number <br />/vz/y