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 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 laws. <br />APPLICANT'S SIGNATURE: <br />cd6t4A, <br />0 PROPERTY / BUSINESS OWNER 2 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 />DATE: 7-26-2024 <br />III New Facility 1=1 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form Az+002v, <br />Facility Name <br />Lodi High School <br />Site Address <br />3 S. Pacific Ave <br />City <br />Lodi <br />State <br />CA <br />ZIP <br />95242 <br />APN Supervisor District <br />Type of Service <br />Requested <br />121 Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />Kiwanis is BBQ'ing for incoming freshman. There is no money involved. <br />If mobile 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 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />Kiwanis of Greater Lodi <br />Last name If contractor, indicate type and license number <br />Non Profit #45-5266295 <br />Address <br />PO Box 761 <br />City <br />Lodi <br />State <br />CA <br />ZW u5241 <br />Phone <br />209-570-3108 <br />Phone Email <br />ckstonyf@gmail.com <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 />Acceptey U <br />Let' t.rtvl C.C., <br />Assigned LinkediA ID <br />Date <br />2-t <br />PE <br />(coq5 <br />Fee 75 et ,.. I, <br />f1/4i6 1`1-414( I <br />Record Number <br />AP240038G <br />0 Cash 0 Check # 0 Confirmation # <br />Payment <br />Received By <br />Rev 07/10/2024