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Existing Facility <br />San Joaquin County Environmental Health Department <br />State y, .Ch-zuK'y <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br />(A D . <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />z»O'Billing Party Facility Contact Contractor ArchitectFacility Owner <br />If contractor, indicate type and license number <br />.Phone Email <br />^K^acility Contact Contractor Architect Billing Party Facility Owner <br />If contractor, indicate type and license numberFirst Name <br />Email <br /> Contractor Property Owner Billing Party Facility Owner Facility Contact <br />First Name Last name <br />StateCityAddress <br />EmailPhonePhone <br />DATE: <br /> OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAssigned To <br />FeeDate 17^ <br /> Confirmation tt <br />(£>2- ~ to/1(Rev 07/10/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <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 /> Check# <br />ZIPState-S- <br />Type of Service <br />Requested <br />Comments <br />-^J^roperty Owner <br />New Facility <br />First Name I <br />Address <br />Accepted By <br />ZIPJ $-<=2 06 <br />ft <br />JLA. ( ( OM S t <br />Phone _ „ Phone <br />that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Ql <br />Citv <br />S <br /> Property Owner <br />Recar dN umber <br />rrPZ-U* 0 _______ <br />Payment /77 A <br />Received ByC/vf (./ <br />Application Form <br />A 'a cos A A d LI q <br />City J <br />(V'Ckzc qvs ^'-7 <br />Facihkv Nam? <br />Site Address <br />^30 Cdli-fo^rifA S-f <br />Supervisor District <br />If contractor, indicat?t>|fc<tf <br />_________________________________________________ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all fft^^r^g^oject <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 <br />Standards, STATE and FEDERAL lawr-^ /A (J <br />■APPLICANT'S SIGNATURE: <br /> OPERATOR / MANAGER <br />State CA <br />Flri<Nameftfc ^1 MrxIgK <br />Address . . < <br />lb 10 cJAt<U/l .