Laserfiche WebLink
New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Lu L u fa e. c i c <br /> site Address City State ZIP <br /> i7341-i S. - reen S s L lit hro c 53�v <br /> APN Supervisor District <br /> Type of Service P9 Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments e r 1 � U 0 Ck A�, Pr <br /> If mobile food truck or License Plate Number WN <br /> pumper truck <br /> Contact Types ❑Ruling Party ❑Facility Owner 3 Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> W Billing Party facility Owner Facility Contact O Property Owner ❑Contractor ❑Architect <br /> First ame Last name If contractor,Indicate type and license number <br /> Address 5 . CST `J fs In clty �� State( ZIP�,�330 <br /> Phone / Phone Email <br /> 1 <br /> LL�rI"`!JjL "� � LAMu+lr�u Ctf41 tri �7. ,�1 <br /> ❑Billing Party ❑Facility Owner ❑Faciiity 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 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:h,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 identifip�on this <br /> farm. f 7 �! <br /> la <br /> I also certify that(have prepared thi pplication and that the work to he performed will be done in accordance with all SAN 30AQll[N COUNTY O�Ipptn <br /> Standards,STATE and FEDERAL s, i�\s / <br /> APPLICANT'S SIGNATURE: DATE' <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT n <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign Is required TitlekR QU�ry <br /> AUTHORIZATION TO RELEASE INFORMATION:When appltcable,I,the owner or operator of the property located at the above site address, <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN 1OAQUIN COUNTY ENVIRONMENTA <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> Accepte By Ass'F ned To Linked FA ID <br /> V,.T,L P adeanne L-. <br /> Date PE Fee Rec d Number <br /> ivrjv R��2�� �I�1 <br /> Rev 06/12/2024 �VL Pat ot j V31�— + ObA2-4 <br /> �� �A0 ace <br />