Laserfiche WebLink
r , <br /> �e,�� n•ems�-z P�. <br /> San Joaquin County Environmental Health Department <br /> Application Form �P�'2'� p S13cib <br /> _ Facility Name <br /> _ Site Address City State ZIP <br /> S c7 <br /> APN Supervisor District <br /> Type of Service ❑Application for W(V4V(UW0Vk OXChange of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN (/ <br /> �pumper truck 1? <br /> Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required Contact Types © <br /> Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> iC � ru-� rr x2 <br /> Address r City 1 State ZIP <br /> P one Phone Email <br /> ❑Billing Party gFacility Owner 0 Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name ,� , <br /> r »+ i <br /> Address City State ZIP <br /> e-A i gr� <br /> Phone Phgne � mail <br /> O Billing Party 0 <br /> �7Facility Owner I �❑/ Facility Contact J ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type an N7' <br /> RECEIVED <br /> Address City State ZIP <br /> Phone Phone Email S5 N g <br /> or 1nx IV: 9ANJOA <br /> ENVI <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge thaMAUT r08PAWMkNT <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 AN JOA IN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL law /� �r <br /> APPLICANT'S SIGNATURE: � L i, �'T/ .fi7'�r RATE: <br /> Sr PROPERTY/BUSINESS OWNER ❑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 By Q{�W a i n Assigned To s Linked FA 11) <br /> Date PE Fee Record Numbers R a 4 m m 145 <br /> S <br />