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San Joaquin County Environmental Health Department Facility Name City State ZIPC(\^705- APN □ Change of Owner □ Repairs or Remodel □ Other □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect Facility OwnerBilling Party □ Facility Contact □ Property Owner □ Contractor □ Architect If contractor, indicate type and license numberFirst Name Last name Address State Email □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect□ Billing Party If contractor, indicate type and license numberLast nameFirst Name Address City State ZIP EmailPhonePhone □ Contractor □ Architect□ Facility Owner □ Facility Contact □ Property Owner□ Billing Party If contractor, indicate type and license numberLast nameFirst Name City State ZIPAddress EmailPhonePhone DATE: □ OPERATOR / MANAGER □ OTHER AUTHORIZED AGENT □ PROPERTY / BUSINESS OWNER Title Linked FA IDAccepted By Contact Types required If mobile food truck or pumper truck □ Application for Operating Permit Phone License Plate Number Type of Service Requested Comments M(nci Le /_______ Phone 5 he 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 the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL law^ . . . . if' C — / // APPLICANT'S SIGNATURE: tAoyVx.AfX DATE: -Z- J Consultation ji ■v 5-^ y 3 G. M (Aril/T cz. CityS^non Date Record Number vin __ Col 12303^ Assigned To Fee i4fcfe -0(D Application Form S'teAddreSS7-90O Supervisor District 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 me release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAl/^M^TH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.7 ^^5^09