Laserfiche WebLink
□ New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />J ZIP <br />26) y <br />APN <br />□ Change of Owner □ Repairs or Remodel □ Other□ Consultation <br />kx <br />License Plate Number VIN <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />ility Owner □ Property Owner □ Contractor □ Architect□ Facility ContactBilling Pai <br />□ Property Owner □ Contractor □ Architect□ Billing Party □ Facility Owner <br />If contractor, indicate type and license number <br />□ Contractor □ Architect□ Property Owner□ Billing Party □ Facility Owner □ Facility Contact <br />•actor, indicate type and license numberFirst Name <br />Addres; <br />Phone Email <br />/ - /3'2-0 2J-DATE: <br />□ OTHER AUTHORIZED AGENT <br />Title <br />PEDate I (©Ost <br />□ Check ft <br />OS 4 9^ HRev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <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, hi <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRO^jg <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />□ Application for <br />Operating Permit <br />Email <br />0 o l/TCoo/c, C-O/^ <br />City <br />Payment <br />Received By <br />City <br />1 State <br />ZIP <br />Last name <br />/•VW* <br />Last name <br />State <br />CA <br />State <br />6^ <br />□ OPERATOR/MANAGER <br />Type of Service <br />Requested <br />Comments <br />Phone <br />First Name <br />CVS <br />Address <br />20 2 4 <br />Phone <br />Supervisor District <br />E'Confirmation If <br />LLC <br />City <br />B/^Existing Facility <br />Email <br />7^ QUA, /noaA Co/h <br />•El Facility Contact <br />To/ <br />Phone <br />Accepted By—yY^ <br />i|i^4 <br />□ Cash <br />Assigned To \ <br />Too <br />-4f eontractoi,indicate type and llttnse number <br />ZIP <br />0 22 <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 FEDERAL laws. A ,n . . - <br /> <br />^PROPERTY / BUSINESS OWNER <br />Site Address;V/Y <br />First Name <br />/)3 AI^OUA <br />Address <br />2~7ZG <br />Phone <br />liaance Codes, <br />13 <br />the <br />Linked FA ID______FA 00 902004 <br />Record Number