Laserfiche WebLink
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 thi a lication <br />Standards, STATE and FEDERAL law <br />and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />APPLICANT'S SIGNATURE: DATE: \\ <br />RECEIVED <br />PAYMENT <br />NOV 13 2024 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 addressg i,S)ANe authorize the tratr <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONM AB n,, Nie <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. IVALTH grpitIENs'47‘.17Y <br />ARTMI <br />0 PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT CD\y\k <br /> <br />Title <br />0 New Facility I:Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />..."ZVM .C\ kQ ‘-kc‘q11(e.k- Site Address <br />V-1,5 ti c.e,,oc.. ViS4-a_ A4e.. <br />ThCity State ZIP <br />APN <br />kr1)1UttA0 L11 <br />Supervisor District <br />Type of Service <br />Requested <br />11 . plication fo4"--) <br />operating Permit <br />0 Consultation GE(Cange of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />\AlZ3)-Nr V\ IW,14 \ C. A j'e Occvm s‘ f.i‘ (L.4- '. if \ •.‘ 4-&'ctA( ) <br />If mobile-food-tr_uck or <br />pumper truck <br />UGen-Se-Nate-N-umbef-- VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />'Billing Party O"Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />&I\e_su 5 CS69,0 <br />Last name <br />SO\-b <br />If contractor, indicate type and license number <br />lP <br /> <br />Phone <br />J*'(Q\,. <br />c'ty <br />) )SlidACO <br />State <br />Or 6'. <br />Actie ch <br />Pi-6A <br />li <br />Phone Email e <br />OkaiNco c..)Q Q.Q.-Nac vy\'‘ one Vel,-.,.co‘;..-i <br />0 Billing Party 0 Facility Owner ErFacility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name <br />(*() k(i2._ / ‘°---- <br />If contractor, indicate type and license number <br />Address <br />SNPQ PS (o-* <br />City State ZIP <br />Phone <br />A09 - q 15 -g7 t 7 <br />Phone Email <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />Accepted By 1... c Assigned To <br />LB <br />--* Linked FA ID FA Geo ( 3 a (2 <br />Date <br />11 -13Ta4 PE icooa Fee At 1 _7 0 <br />11-1.----- <br />Record Number sRa4-00640 <br />-tA./(-Pa"72k.502\jsLtt-illact9I <br />Rev 06/12/2024