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Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />City State <br /> Consultation Change of Owner Repairs or Remodel Other <br /> Facility Owner Contractor Property Owner Architect <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />Last name If contractor, indicate type and license number <br />State <br /> Billing Party Facility Owner Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone EmailPhone <br /> Facility Contact Property Owner Billing Party Facility Owner <br />Inse numberFirst Name Last name <br />Address City <br />Phone EmailPhone <br /> OTHER AUTHORIZED AGFNT OPERATOR/MANAGER PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAssigned ToAccepted By <br />Date boD'> <br /> Check it Cash <br />Rev 07/10/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <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 />DEPARTMENT as soon as it is available and at the same time It Is provided to me or my representative. <br /> Application for <br />Operating Permit <br />Payment <br />Received By <br />If contractor, indicate? <br />ZIP <br />j’Jflitect <br />Type of Service <br />Requested <br />Comments <br />Site Address <br />APN <br />< 7 <br />PE <br />VIN <br /> Facility Contact <br />Confirmation it <br />□ Contractc^^^i^^ <br />First Name <br />A_____________ <br />Address <br />K \ r <br />■ Phone Phone <br />Record Number „ .| SR2.^ <0\ 2Cp <br />License Plate Number <br /> Billing Party <br />CiLV . <br /> Facility Contact <br />State u U <br />___________________________________________ HEALT* oePA'rr- <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 anfflhat the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL l^sTVv 7 ~ 7 /-c ' <br />APPLICANT’S SIGNATURE: ----- DATE: 6/ 7/ 6^/ <br />/Email <br />s-~ <br />Supervisor District <br />Fee$\-H