Laserfiche WebLink
❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form 250 QD 6-12- <br /> Facility Name <br /> Q C5 ' Cl 01Q V1 7 CiL <br /> Sit Address City State ZIP <br /> It) 5 NYLO vu ko c <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑ConsuEtation Change 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 e L3 [j U <br /> Contact Types ElBiIling Party ❑Facility Owner ❑Fac€lityContact ❑Property Owner ❑Contractor 7ArchItect <br /> required <br /> r15 Billing Party 4facility Owner i0 Facility Contact ❑property Owner ❑Contractor ❑Architect <br /> First Name Last name if contractor,indicate type and license number <br /> vQr C' Go <br /> Address City State ZIP <br /> 1 t C o �n <br /> Phone Phone Email <br /> 910 6 1V'4-'A+r-2-356 , 0004-r—PAI <br /> 17 Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner II Facility Contact 7operty Owner ❑Contractor -T❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> 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 PA <br /> APPLICANrs5 GNATURE:ERAI�FB 1' 1/CY[�YC�C �76Yt ZQ C_L DATE.A , b N NE1Vr <br /> �ROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT i;VeD <br /> TitleJUL 0 Z 20?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 add thorize t e <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRO k ; ly <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. 1YF�� NT <br /> �N <br /> Accepted By Assigne To Linked FA ID <br /> Date PE (0 d y Fee Re44rdNumber 0& rm <br /> all b-� 0&1 c& <br />