Laserfiche WebLink
New Facility l "Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name __.-.. <br />a 0 --T IA.c.k5\- <br />Site Address <br />v\Ac ,1/4- c0- <br />City , <br />S toCMov\ <br />State <br />C A <br />ZIP <br />. 5 Z OZ- APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation VECige of Owner 0 Repairs or Remodel 0 Other <br />Comments <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 />0 Billing Party krFacility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name ka Last name <br />-1(Y1 :*k <br />If contractor, indicate type and license number <br />Address <br />I 5 2- I G-Ck u MA , --- -e k Q-le_ <br />City , <br />s's k-cc.h-cAl, <br />State ZIP c A 45Z, 0-Z- <br />Phone <br />Z e)C1 4.2l,0. <br />Phone <br />CS <br />Email <br />0-44(V-01 i4NS nix i A-4-, 01-0 s-Ajcsiktz f Co t"-. <br />0 Billing Party 0 Facility Owner 0 Facility Contact 10 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 />and Atippmber First Name Last name If contractor, indicate type <br />Address City State Z I <br />Phone Phone Email g <br />%,/ <br />., <br />,..„ e.. - %M.-. e0A <br />A /4/ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge t <br />E <br />ggbis <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as Athi <br />form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL Iaws <br />APPLICANT'S SIGNATURE: DATE: <br />PROPERTY / BUSINESS OWNER <br /> <br />El 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, hereby authorize the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />Accepted I ..,c,A_ <br /> r‘ivues e----b <br />Assigned To 1 , <br />'M LAA D <br />Linked FA ID <br />FA 0001 32'8 <br />Date <br />t-1-12-5- <br />PE <br />I 6 OZ <br />Fee <br />l -i- 2 -CT <br />Record Number <br />5R-2.5001 2 <br />0 Cash 0 Check # Confirmation # )(3535-372_— <br />Payment <br />Received By <br />TRU 0g,-10 Rev 07/10/2024