Laserfiche WebLink
i <br /> New Facility )(I <br /> xlsting Fadlfty <br /> (needs 5RK) <br /> San Joaquin Counter Environmental Health Department <br /> Application Form <br /> Fac11KY#+ams <br /> SIIeAddress Crty� J 5tit� IP <br /> 11,pk'1 i <br /> APN Supervisor DlstdCt <br /> f - 11b 5 <br /> Type of$¢rose* 0 Appliul lore far ElConiuWFon ElChange of Owner ❑Repalrs or Remodel other <br /> Requr~5ted CFperatfng Remit <br /> Comrncrtii <br /> If mob0e food tnrck or License Plate Number WN <br /> pumpar truck <br /> Contact Types It Will Party U FiWlly Owner 0 Faculty Canta€t ❑Property Owmar 3 Corstracwr fhgYestor <br /> requlred <br /> eliding Party ❑F7c111ty Owner Facility Cantacl ❑Properly OwnerVN <br /> orttrartor ArChlt�ct <br /> Flr Mama Last n�m e I oonua r,indicate type and Ikcense number <br /> Address r,Jty Slate IIP <br /> Jau ti b CA <br /> P� Jaholtr Emat1 <br /> l r( -V 'ate 15 aexr <br /> 0 61111ng Party J 0 Fadlity Owner ❑Fa€11 rty Contact 0 Property Owner ❑Contrarmr ❑Arch7rert <br /> First Marne LaA namt, it rontra�tq.r,IndKatc,type and liwse number <br /> Address City State ZIP <br /> Rhone Phone Email <br /> ❑-Billing Party Q Fadlity Owner ❑Fardity Comm 0 Prwrty Own v ❑ConluCtor Q Architect <br /> First Narne Las#name If contractor,IndleMe type and Ilcense number <br /> Address ow State 4I12 „O <br /> Phone Phone EmMl <br /> '- <br /> ORMHO A1CKNCfflA DEMENT;),the unders*wd properly or husinem owner,operator or auftlized agent of same,acknowledge that all rile " <br /> spec flc f RAFL NIVIt NTAL HEALTH f]EPAR7MEM7 hwrbv Charges assocrated wltla this project or acivILY will be b11led to me or my hoslness a s Neat a fps to f <br /> form. , <br /> I also certify Thal I h5ve prepared♦#Ifs oppl Rion and i1hW9 th[work to he performed Will he done In accordance withal SANJOAQUIN COUNTY OFdlnuue Codes, <br /> Standardy,STATE and FETE Iawa <br /> Appucors 51OHA7URE: E1ATE S I <br /> 11 PAOPEM/6USINESS OwNEFt Ll OPEIWTOR/MANMER 167liE$C AUTHORIZED AGENT` C- ,N,3r c ' <br /> If APPLICANT Ii nal the AILLING PAPTY,proof of autho0zal Ian 10 sign f1 req ulmd <br /> AkUMORIZATION TO AEL ASE INFORMATION:When appllrahle,1,the owner or op-erator of I he property kc6ted A the■hmm site addrt5%hereby authorke the <br /> release of any and 411 results,geolechnlcal d ata i nd{or eovlronmemaVsaa asaasmant Information to the SAW JOAQI,1fN COUNTY ENMROAM E NTAL tl$AL'FN <br /> DEPARTMENT ai so41,ai It JS available and at tare same time.It Is provWed to me or my representative. <br /> ADCOPIMk a Assigned T Linked FA ID <br /> Le <br /> J7rtte e i [ Gaff Record N r r <br /> 50 <br /> 15 <br /> 0 Cas h ❑Check N ConfkmotHm It Payrrent <br /> — — , Rtcalwed By <br /> Rew47{Lgfq 2 of 13 <br />