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Application Form City State ZIP Supervisor District Consultation Change of Owner Repairs or Remodel Other FFl License Plate Number VIN Billing Party Facility Owner Facility Contact Property Owner Contractor Architect ^Billing Party Facility Contact Property OwnerB Facility Owner Contractor Architect If contractor, indicate type and license numberLast name City State ZIP Phone Email mhrecreation@sjgov.org Contractor Architect Billing Party Facility Owner Facility Contact Property Owner If contractor, indicate type and license numberLast nameFirst Name Address City State ZIP Phone EmailPhone Facility Contact Contractor Property Owner Architect Billing Party Facility Owner If contractor, indicate type and license numberLast nameFirst Name City State ZIPAddress EmailPhonePhone Nr DATE: OPERATOR / MANAGER PROPERTY / BUSINESS OWNER ry :Nr Linked FA IDAssigned To Fee (7 2--2^ Cash Check # Rev 07/10/2024 Contact Types required Application for Operating Permit Date ’7- First Name City of Mountain House Address 251 E Main Street, Mountain House, CA 95391 Phone 209-831-2300 Facility Name Central Community Park Site Address 25 E Main Street, Mountain House, CA 95391 APN Type of Service Requested Comments National Night Out If mobile food truck or pumper truck B OTHER AUTHORIZED AGENT Recreation Manager Title 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 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 Ordio/nrery^yLy a » . Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: Laura Johnston DATE: ”25/24 C?/'EC^, 2i If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required ^0)^ Q(j. AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address^fg^bVatKl^r^^Q^^ release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL^! DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.A?/ Accepted By c-O PE ^4 New Facility Existing Facility San Joaquin County Environmental Health Department ^Confirmation it | Received By{