Laserfiche WebLink
❑ New Facility (Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name fAP SAI&I4 G-4y - - -- <br /> Site Address `, )W! 1-�� MAW City <br /> /� W '4 State ZIpi�I � ?�OlZ�fo <br /> APN Supervisor District <br /> I <br /> Type of Service Application for q Consultatlon ❑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 truckE== <br /> Contact Types Q Billing Party WFaclftty Owner ❑Facility Contact 0 Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party Facility Owner :10Facility Contact ❑Property Owner ❑Gantrattor ❑Architect <br /> First Name ®_r�;� ,/ ' Last name /� If contractor,indicate type and license number <br /> Address `w� ' ,! City state^j ZIP <br /> phone -Email ;-PVA1A <br /> ❑Billing Party ❑Facility Owner Cl Facility Contact ❑Property Owner M Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> R <br /> City State ZIP <br /> Phone == Email <br /> ❑Billing Party ❑FacllityOwner ❑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 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. d <br /> I also certify that 1 have prepared this a p al and at the work to be performed will be done in accordance with all SAN OAQUIN COUNTY O P� <br /> Standards,STATE and FEDERAL law h7 CY <br /> APPLICANT'S SIGNATURE: DATE. /� V <br /> /PROPERTY/BUSINESS OWNER ❑OPER OR/MANAGER []OTHER AUTHORIZED AGENT �4�-.AO( 0 20 Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign Is required JOAQUlN <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site addrefi i J�����C�� oN <br /> release of any and all results,geotechnicaI data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMEN LiR/gtt�r{„ AL <br /> DEPARTMENT as soon as it Is available and at the same time it Is provided to me or my representative. "`r14N <br /> Accepted By Assigned To nag <br /> . Unked FA ITS Jj 0 0/ <br /> Date^ Z PE I j„0� Fee ,'2, Record Nurnber'�f �") <br /> 3VIr t(✓ �(y�/� � SR 2 yW 3SZ. <br /> Rev 06/12/2024 I :l`11> `T1 `�f /�I �q F k&v� <br />