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New Facility Existing Facility San Joaquin County Environmental Health Department Site Address APN Consultation Change of Owner Repairs or Remodel Other VIN Billing Party Facility Owner Facility Contact Property Owner Contractor Architect Facility Owner Facility Contact Property Owner Contractor Architect If contractor, indicate type and license number Phone Billing Party Facility Owner Facility Contact Property Owner Contractor Architect If contractor, indicate type and license numberFirst Name Last name Address City State ZIP Phone Phone Email Billing Party Facility Owner Facility Contact Property Owner Contractor Architect If contractor, indicate type and license numberFirst Name Last name Address City State ZIP Phone Phone Email DATE: OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER Linked FA IDAssigned ToAccepted By PE Fee1^6 Confirmation # Cash Check # Rev 07/10/2024 If mobile food truck or pumper truck 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 environmental/site 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. Application for Operating Permit Email Type of Service Requested Comments zip ^Billing Party 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 rfijriit. 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 laws. J ,1 x? J rp ' APPLICANT'S SIGNATURE: DATE: /L^ <— ^ / OPERATOR / MANAGER OTHER AUTHORIZED AGENT Title Payment Received By 7h/| ^ity i r state/- a C A ________________Application Form FacdityName f t H (7 15*4 Pi Supervisor District ypEol-l* 7| 575-6 ZIPq‘f-52.grState „C A License Plate'Number Last name . . - z* a. iZk^l la ka if i v P ‘T/ ClA O Kjt