Laserfiche WebLink
El New Facility xisting Facility <br /> (needs SR#) <br /> San Joaquin County Environmental Health Department <br /> Application <br /> Form <br /> Facility Nam"— <br /> -5 <br /> Dui <br /> Site Address Cl� 1 State t 'L <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation ❑ Change of Owner Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truckorl License Plate Number VIN <br /> pumper truck <br /> Cortact Types ta Bilong Party 11 Facility Owner I IN Facility.Conta'd prol 0 Requestoii <br /> required <br /> r <br /> filling Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner M <br /> actor ❑Architect <br /> F' s Name, Last name cto ,indicate type and licen a number <br /> Add r }s I t�ity - State ZIP <br /> Phone Phone Email <br /> LC <br /> ❑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 ❑ 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: 1,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 FEDER L ia4. f1 j j <br /> APPLICANT'SSIGNATURE: ! � 3 _/ DATE: 1�7 f 702 <br /> ❑ PROPERTY/BUS]NESS OWNER ❑OPERATOR/MANAGER OTHER AUTHORIZED AGENT C r��� j�L/ <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required �J <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT as soon as it is available and at the same time it is provided tome or my representative. <br /> Accepted BS' a, e'V/ �1V Assigned , j tlnked FAiD <br /> Hs 1y� 8 <br /> Date I � Fee �; Record Num <br /> ❑Cash O Check# ❑Confirmation# Payment <br /> Received By <br /> Rev 07/10/2024 2 of 6 <br />