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Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />Site Address <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br />(2^ <br />VIN <br /> Contractor Architect Billing Party Facility Owner Facility Contact Property Owner <br />' Billing Party Facility Owner Property Owner Contractor Architect Facility Contact <br />If contractor, indicate type and license number <br />Zl5> r- <br />3^1,9 <br />Email <br /> Architect Property Owner Contractor Facility Owner Facility Contact Billing Party <br />If contractor, indicate type and license numberFirst Name Last name <br />ZIPAddressCityState <br />Phone EmailPhone <br /> Contractor Architect Property Owner Facility Owner Facility Contact Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />State ZIPCityAddress <br />EmailPhonePhone <br /> OPERATOR / MANAGER m id 2026 PROPERTY / BUSINESS OWNER <br />Title <br />Assigned To <br />PE <1 <br /> Check tt <br />9^0\lPCM9-'4-Rev 07/10/2024 <br />I <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />ri^eShc- <br />TH <br />.......7 <br />nlLast nameFirst Name <br />('u.onQ <br />.‘.Jdress xj <br />ZIPState <br />Type of Service <br />Requested <br />Comments <br /> Application for <br />Operating Permit <br />Address xJ , ' \ 1 n <br />EHSG .CpninqMoAd waU <br />Rhone J=m|ne J <br />408-0^-^350 <br />Linked PAID <br />^Confirmation # 22 S' | Rec^d By <br />License Plate Number <br />Application Form <br />T~ <br />(o3l Cerd-er ‘xt- <br />• Supervisor District <br />ihat the work to be performed will be done in accordance with all SAN JOAQUIN COUNTYj'OrJlnance Codes, j <br /> DATE: (7$ 15? / 2O2£ RECEIVEP <br /> OTHER AUTHORIZED AGENT <br />City <br />Sloe K- hrrx <br />BILLING ACKNOWLEDGEMENT: I, the undersigned 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 aj <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required n . <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authc <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL Hf Al <br />DEPARTMENT as soon as it is a va i I a b I e a n d at the same time it is provided to me or my representative.Ufc. <br />Accepted sf' <br />Date ~ <br />5-lg-3to <br /> Cash <br />State <br />G5