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S/New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />State <br />APN <br /> Consultation Change of Owner Repairs or Remodel <br /> Contractor Facility Contact Property Owner Architect Billing Party Facility Owner <br />OTroperty OwnerB^illing Party SJ-PJctlily Contact Contractor ArchitectSH’acility Owner <br />If contractor, indicate type and license numberLast name <br />State <br />^Ctfntractor Architect Property Owner Facility Owner Facility Contact Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name <br />O-rirchitect Property Owner Facility Contact Facility Owner Billing Party <br />First Name <br />DATE: <br />WITHER AUTHORIZED AGENT lOl OPERATOR / MANAGER PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAssigned To Lydia BakerAccepted By Vidal Pedraza <br />PEDate 16015/6/2026 <br />Rev 06/12/2024 <br /> <br />payment 220371427 <br />MAY 0 6 2026 <br />Contact Types <br />required <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARLMENI as soon as it is available and at the same time it is piovided to me or my representative. <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTMENT <br />Type of Service <br />Requested <br />Comments ouf nwtee-TS. <br />Phwm-Wii <br />_________ <br />flabU speech- rUskCftm <br /> Contractor <br />^D8)^C> | ^Set-Vctg* i rm t <br />If contractor, indicate type and license number no8ofc»~7 <br />z,p^// <br />Record 2, <br />RECEIVED <br />2'P^3Z9/ <br />La5'"am* /?7^r If contractor, indieCaCnenil <br />sa,e Oy <br />State /OCA <br />______ Application Form <br />2221^ <br />um <br />Supervisor District <br /> Application for <br />Operating Permit <br />ftr? ac/Krna de PP/miL Ao -fixd At) <br />If mobile food truck or "License Plate Nuaiber VIN <br />pumper truck <br />J2^r\________ <br />Ave-HL <br />Ph°" Ik^-g^r1’131' ____ <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 and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. --------- / ( a ]^7 4, <br />APPLICANTS SIGNATURE: DATE: ‘—W---------------------------------------------------- <br />BsT <br />Addras 'iD^Per^icqAvcSuAe/V <br />»r*s phf>UtS. | kJ Email » \ <br />Fee ‘ 537