Laserfiche WebLink
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 d that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL <br />APPLICANT'S SIGNATURE: <br />aws4 <br />DATE: <br />SAPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />Title <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, h§t4ii <br />release of any and all results, geotechnical 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. <br />orize the 0474 <br />COO fribi tivrY <br />• <br /> p)z 0 SLI <br />San Joaquin Joaquin County Environmental Health Department <br />Application Form <br />Facility Name„...--- <br />CA-14A i V\ IS '1C19V WCIA'' <br />Site Address , ar <br />)() 'S ' ,,e3(C'Y gimeiP_Aki(o ,C1- <br />City <br />L-06Q-1 <br />State <br />LA <br />ZIP <br />c 1 _S 2 0 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation rgsChange of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number • <br />6? ST7e.(0.1 <br />A . <br />P3 V1 <br />I .-, VIN 1 <br />1/ (4 8 3 3,06(.8 <br />Contact Types <br />required <br />'Billing Party ''Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name k Last name A <br />ki L i <br />If contractor, indicate type and license number <br />Address . itt 62, CA,_( 0,14A 0,Y Mit C:4- <br />City <br />Pikt/VA C". <br />State c., A ZIP <br />f 5 31- <br />Phone fq 3M <br />Phone Email <br />10-1,1 /4zei 2_ (:, 1 Q i•io•eit k • ,,..-- <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />Accepted By <br />c. <br />3_e_ Assigned To Fr 0.,r1 c i s co <br />R.• <br />Linked FA ID _ <br />FA 0CD 2:4 cm k <br />Date,c5 2.i PE KoW5 Fee *.e\ k42,2_ Q:,„(b Sitar- <br />Record Number SR a 4 00 t I? <br />pa 1 ct 60 /Lck I lb I i-51a3o-9- M/07-d