Laserfiche WebLink
pp'o sq �� - <br /> 3 San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> "'w'+ti 's I cvy?v�x'� <br /> Site Address U City State ZIP <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation %Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number / VIN <br /> pumper truck CJ rJ1 33p z� <br /> Contact Types Billing Party 14 Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name <br /> /QQ—,W` Last name'(�I^ L i If contractor,indicate type and license number <br /> Address. City State ZIP ,z <br /> l 6 2— A a� M�.vt�fQ s � - <br /> Phone b Phone Email ^ `µ <br /> ❑Bulling Party ❑Facility Owner ❑Facility Contact rN ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <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 ation d that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and <br /> APPLICANT'S SIGNATURE: <br /> ws. DATE: D J l -04 r,, <br /> VOPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT �Z6t/ &r <br /> Title D <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Af*? <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hA%,1dhorize the a� 7 <br /> release of any and all results,geotechnicaI data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRON <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. �Ntij COL/ <br /> Accepted By a Assigned To Linked FA ID T <br /> C. Fra.rnci sco R• -AOTS-4 <br /> Dat � PE � � Fee�1b2 ^ � Record Number <br /> Pat 19 wl�f <br /> S� <br />