Laserfiche WebLink
(Ja) XNew Facility ❑ Existing Facility <br /> /c <br /> 5 <br /> S . n Joaquin County Environmental Health Department <br /> Application Forma Ug g g <br /> Facility Name <br /> D o l o r U- L.o h 0� o 0 <br /> Site Address City State ZIP <br /> e,5C. o '�5 TQac. �5"3�1 b _ <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 /> C -If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact El Property Owner ❑Contractor ❑Architect 1 <br /> required <br /> I <br /> Billing Party KFacility 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 /> v 2.1 5 <br /> Phone Phone Email <br /> g z s S i is a)o'-X <br /> ❑Billing Party Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> vt"-Q- aS 4-►06 <br /> v <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 this application a hat the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws <br /> APPLICANT's SIGNATURE: DATE: a�i z R L2 /�V I�4 <br /> OPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT RZ F ENT <br /> Title �VeD <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required AtiG Qp <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site ad*rss,hereb?JhQ y jfe <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY EN VI HEALT H <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative, y &140-- k Cc), <br /> ���---m�-r--A <br /> Accepted By Assigned To Linked FA ID A4�T 1 <br /> t <br /> Date PE Fee RecP�d Number <br /> lag H ( !7� AP2`/00988 <br /> �/ Payment <br /> ❑Cash ❑Check# L"1 COnflrmatlOn# Received By <br /> Rev 07/10/2024 <br />