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 ho L 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 t s tion t the w.r I. perfor d will be done in accordance wit IllA1/.10 UIN COUN 0 inance Codes, <br />Standards, STATE and FEDER L I <br />APPLICANT'S SIGNATURE: <br />0 PROPERTY / SINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <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, 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 to me or my representative. <br />Title <br />New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Wee e.'" <br />Cr( G... 4$-1- v , / , rim 0 ia Poi eeratc/v1 Stateciet__ <br />5i3a <br />APN upervisor District <br />Type of Service <br />Requested <br />S!liApplication for <br />perating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />License Plate Number If mobile food truck or <br />pumper truck <br />1 VIN <br />dt--=',•; - <br />..:F101141.?*.t.V: <br />':"•''' ' c--•• ••• ,, _-. <br />••• --- ..P190,4)1:- i;i;leref • <br />'11. ..--i' - <br />. O. FadIRYSMact 9 .. ; ...,-., ...,,i..._-....:_,.....,„,,:. .. <br />'13.Piopeity.Ovint i7.:. ..: , ..;:.:, :i...-.L .ip:p1irei --; _ • ,., r• . - <br />'ZLBilling Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First N\ me (\Sic Las na Lv\s If contractor, indicate type and license number <br />Addresg, IA rael? <br />I <br />d 51e, A., lay t do StapAg_ ZIP(;i 537 (e) <br />rcoisOef 05 ixt162 & Email [ / 4 / 145 „ ArteZsq, co-Yin <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 />ID 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 />. • \.(\\r\c\- ie., Assigned To <br />' f-\\-/\ - (—Ai e .s <br />Linked FA ID , <br />. <br />, <br />Dat • <br />. . ' 2- <br />PE . ,._. <br />\ 43CA <br />Fee - <br />-9- -2_ i <br />Record Number <br />P ..,.. .. _. <br />0 Chec k ck # 0 Confirmation 1 "c. k ft <br />-1 i 0 3 — • .- - ,;.',..,,.p, ..,... <br />Rev 07/10/2024 <br />n 0\ V-__v sv\ e 2-0c‘ Pe 24 W351