Laserfiche WebLink
Rev 07/10/2024 <br />New Facility lExisting Facility <br />San Joaquin County Environmental Health Department <br />Application Form eQ_En-395 1 <br />Facility Name <br />01-72.65 1,) -Tme <br />Site Address <br />2'7 0(7 ‘PP V"--1") PVI,J( 4 ) D \ <br />City —... State,. A ZIP <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />C., <br />„,„ i <br />V\P‘st.n. c-) , .6--r- \.s.:- 0— <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />1 <br />,-Billing Party 0 Facility Owner CI Facility Contact 0 Property Owner ' 0 Contractor 0 Architect <br />Firsalame <br />Tpc 3 I w•J 06 11— legi-Wit4 <br />Last name If contractor, indicate type and license number <br />jvl I A/ 11 A S <br />Address <br />cl- <br />City <br />- --57-p c ?' <br />State ZIP <br />ILI ki 6pc14 <br />Phone <br />(2C-51 4 67 "l'ilo <br />Phone Email <br />LI Billing Party 0 Facility Owner ,,Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name ), <br />C-ViA0d 17 (2-6 1 C \NO\ ( f\ <br />Last name <br />tv i -,5- 5•Q.- <br />If contractor, indicate type and license number <br />Address , , City State ZIP <br />Phone <br />116;43) 35,--Si1 2 6 <br />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 />BILLING ACKNOWLEDGEMENT: <br />specific ENVIRONMENTAL <br />form. <br />I also certify that I have prepared <br />Standards, STATE and FEDERAL <br />APPLICANT'S SIGNATURE: <br />ROPERTY / BUSINESS <br />If APPLICANT is not the BILLING <br />AUTHORIZATION TO RELEASE <br />release of any and all results, <br />DEPARTMENT as soon as it <br />I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <br />HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br />this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />law L, ...._„---- DATE: q " /q '2 11 PAY4f <br />OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />PARTY, proof of authorization to sign is required <br />INFORMATION: When applicable, I, the owner or operator of the property located <br />geotechnical data and/or environmental/site assessment information to the SAN <br />is available and at the same time it is provided to me or my representative. <br />.RZCP EAfr ...IVA." <br />Title <br />i <br />at the above site addigfiri j eby authof+Mdlie <br />JOAQUIN COUNTY ENV 4M1/41,EALTH <br />tfekrii 0A//044-447-1, <br />DEpA rilz i.A <br />No.. <br />Accepted By/- . Assigned To <br />"liT <br />Linked FA <br />D <br />a -) 1-21- <br />PE <br />1(002-- <br />Fee ..---- Record Number <br />SR a40050(p <br />0 Cash 0 Check it Lit C <br />„/ <br />onfirmation it i86 0 ra2..-,C3 <br />Payment <br />Received By *77