Laserfiche WebLink
LIB n Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />Fl e Last name If contractor, indicate type and license number <br />ress City State ZIP <br />Phone Phone <br />\ <br />Email <br />UJUNG 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 up lication 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 9 <br />APPUCANT'S SIGNATURE: DATE: <br />ipROPERTY/ BUSINESS OWNER Ci`OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />If APPUCANT Is not the BIWNG PARTY, proof of authorization to sign Is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN <br />DEPARTMENT as soon as It Is available and at the same time It is provided to me or my representative. <br />Title <br />at the above site address, hereby authorize the <br />JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />PAYMENT <br />RECEIVED <br />116 23202k <br />30AQUIN COUNTY <br />pRONMENTAL <br />iit.AL DEPARTMENT <br />0 New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />AoDlication Form . . <br />Facility Name <br />r.\ <br />Site Address City State ZIP <br />APN Su ervi5or District <br />Type of Service <br />Requested <br />Application for <br />Operating Permit <br />0 Consultation 0 Change 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 />2-Billing Party la-Facility Owner 0-Facility Contact zi Property Owner 0 Contractor 0 Architect <br />.0-8111Ing Party 2-Facility Owner O'FacIlity Contact JaProperty Owner 0 Contractor 0 Architect <br />Nrat Name Last name <br />\P0100 - ',c YiA rY\ ,C' kj h <br />If contractor, Indicate type and license number <br />Ad ress <br />°P2D1-1. COooin C\— City , State , et ZIP ct CD2_142_ <br />Phone Phone <br />1-°1 <br />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 />Accepted By /- _ Assigned To — - Linke4M /1151D -._- <br />Date <br />.c! 12] 214 PE l_tcD ' Fee I ( g6 Record Number <br />Cit.) 24 TOCU3Q , <br />0 Cash "Check <br />heck II 61 q-, , 0 Confirmation # 2/0-03--i 4, Payment <br />Received By iky---- <br />Rev 07/10/2024 .14.)*