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San Joaquin County Environmental Health Department <br />Application Form <br />1FacililvSai Events <br />Sit* Andres*.City State | ZIP 95336MantecaCA <br />ARM <br />fyi Si^e. <br />Fl Change of Owner Other <br />X Facihty ContactX Facility Ovrncr Property Owner Contractor Architect <br /> Billin’ Party Facility Owner Facility Contact Property Owner Contractor Architect <br />First Name last name If contractor. Indicate type and license numberHarjinderShade <br />Address City State ZIP <br />4704 E Hildreth Ln Stockton CA 95212 <br />Phone <br />i5snitch@gmail.com <br />I Billing Parly U Facility Contact U Contractor <br />last name <br />' City State ZIP <br />EmailPhonePhone <br /> Contractor Facility Owner Facility Contact Architect Bill ng Party <br />If contractor, indicate type and license numberFirst Name last name <br />City ZIPAddress <br />’0PhoneEmailPhone <br />8-15-25DATE: <br />X PROPERTY / BUSINESS OWNER X OPERATOR / MANAGER OTHER AUTHORIZED AGENT <br />Assigned To Linked IA II)Accepted By <br />PRzWi? I <br />Contact Types <br />required <br />Email <br />indusfive@yahoo.c >m <br />BILLING ACKNOWLEDGEMENT: I. the unde'signed 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 this application and that the work to be performed will be done In accordance with all SAN I0AQUIN COUNTY Ordinance Codes. <br />Standards. STATE and FEDERAL laws. <br />APPLICANTS SIGNATURE: <br />Phone <br />408-410-4011 <br />Record Number <br />AP2^>Q) VS <br /> Property Owner <br />State <br />First Kame _____ <br />Address <br />Type of Service <br />Requested <br />Comments <br />Member <br />Title <br />2111 Moffat Blvd <br />Supervisor District <br />IX Billing Party <br />PE\hCD3 <br />______] <br />X Application for Consultation <br />Operating Permit <br />Cc I <br />If mobile food truck or license Plate number * [ VIN <br />| pumper truck <br />V (■ <br />C'^l2C <br />It APPLICANT Is not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: VZhen applicable, I, the ovzner or operator of the property located at the above site address, hereby authorize the <br />release of any and all results, gentwhmcal data and/or erwironmenUl/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 er my representative. <br /> Repairs or Remodel <br />Fee <br />| U Facility Owner | U Architect <br />if contractor, inoicatc type and license number <br />| U Property Corner <br />-