Laserfiche WebLink
D New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form PQ-ok6ti obc) <br /> Facility Name <br /> Site Address �l rty State Zi <br /> C[_ <br /> APN Sup rvisor District <br /> Type of Service ❑Application for ❑Consultation Uthange of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> if mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Biking Party ❑Facility Owner 1]FadElty Contact ❑Properly Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact UProperty,Owner ❑Contractor ❑Architect <br /> Firs me Last name tf contractor,indicate type and license number <br /> l7 <br /> Address ,� Ci State ZIP <br /> C <br /> Phone Phone Emai1 a .nG <br /> Z <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ff Property Owner ❑Contractor ❑Architect <br /> First Name Last name if contractor,indicate type and license number <br /> Address /j City State ZIP <br /> Phone + Phone Email l moc <br /> [IBilling Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor 7'chitectPAvm. <br /> First Name Last name If contractor,Indicate type and licerrgm r <br /> Address City State ZIP K C D <br /> JUN <br /> Phone Phone Email H J 5 <br /> oa <br /> WILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed tome or my business a71dentiflilidont <br /> form. <br /> also certify that I have prepgf plicatlon and t at the work to be performed will be done in accordance w th ali SA JOAQUIN COUinance Codes, <br /> Standards,STATE and FE RALlaws. r <br /> APP NT'S SIGNATUi�L � DATE <br /> G PROPERTY/BUSINESS NER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT _ <br /> Trtle <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,t,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 /> Accepted By Assigned To Linked FA ID <br /> f A. <br /> Fee _ Record Number <br /> �� 25 PE �\'oc�Z S9,250 1 2-®Z <br /> I7 CaSFt ❑Check# Confirmation k "j Q`� _ Payment <br /> Received BY <br /> Rev 07/10/2024 <br />