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(MilftY N*nw State ZIPCAS«r AAlir*'95391 Repairs or Remodel Other Change of Owner Consultation Contractor Architect Property Owner Facility Contact Facility Owner Billing Patty Architect Contractor Property Owner Facility Contact Facility OwnerBilling Party If contractor, indicate type and license numberLast nameFirst Name MariottiMonica ZIPState 95391Address120 S. Libertad St.CA Contractor Architect Property Owner Facility Contact If contractor, indicate type and license numberLast name ZIPStateCityAddress EmailPhonePhone Architect Contractor Facility Contact Property Owner Facility Owner Billing Party If contractor, indicate type and license numberLast nameFirst Name ZIPStateCityAddress EmailPhonePhone XJ OPERATOR/MANAGER XFHER AUTHORIZED AGENT Assigned To Linked FA ID Fee Confirmation N Cash Check # 25 Main Street Supcivlsoi District it mobile food Huck or pumpei truck T\ve of Scnxv Contact Types required 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 envlronmental/slte assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as It Is available and at the same time It Is provided to me or my representative._____________________________________________________ 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 appj|wti; Standards, STATE and FEDERAL law^ APPUCANTS SIGNATURE: // JT' Billing Party Facility Ownerhey, First Name Date Email hispaniemoho ©qmail.com City Mountain Hou^e Application for Operating Penult Community event to take place at Central Park in Mountain House on 10/12/2024 l^oy VendorAruck info provid scf. See Event Application. PROPERTY / BUSINESS Accepted By lx Record Number. _ .Apa401124 Payment Received By | kr\ ^24003^5 San Joaquin County Environmental Health Department Application Form Mountain House Hispanic Heritage Festival City Mountain Hoise PhoneI Phone (209)669-2706 pF" Ind that thy work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, * DATE: /Io [or l^<L/ . Founder________ Title