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(i/ New Facility □ Existing Facility San Joaquin County Environmental Health Department Application Form 5 □ Other□ Repairs or Remodel□ Change of Owner□ Consultation VINLicense Plate Number □ Architect□ Property Owner □ Contractor□ Facility Contact□ Facility Owner□ Billing Party 1^ Billing Party □ Contractor □ Architect□ Property OwnerH Facility Owner □ Facility Contact If contractor, indicate type and license number Email □ Architect□ Contractor□ Property Owner□ Facility Contact□ Billing Party If contractor, indicate type and license numberLast nameFirst Name ZIPStateCityAddress EmailPhonePhone □ Architect□ Contractor□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party If contractor, indicate type and license numberLast nameFirst Name ZIPCityStateAddress EmailPhonePhone JrlO-ZOlkDATE: St PROPERTY / BUSINESS OWNER □ OTHER AUTHORIZED AGENT □ OPERATOR / MANAGER Title Linked FA IDAssigned ToAccepted By Record NumberFeePEDate □ Confirmation It□ Check «□ Cash 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. Contact Types required Payment Received By Last name S rln'i State Czxh/o j'ni C-\ ZIP ZIP ''-^5 57 First Name Address tiS6 xa.1 2-°\ Phone Phone City Facility Name Th Site Address ' _h S5 APN a7-0302F Type of Service Requested Comments 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 laws . I f. in APPLICANT'S SIGNATURE: P AAA k- If mobile food truck or pumper truck City Phone Phone Email . □ Facility Owner State r H OyVn'm Supervisor District __________ M Application for Operating Permit