Laserfiche WebLink
Existing Facility New Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />State <br />APN <br />^E^thange of Owner Consultation Repairs or Remodei Other <br />License Plate Number VIN <br />A--' <br /> Facility Owner^S^illing Party Facility Contact Property Owner Contractor Architect <br />Last name If contractor, indicate type and license number <br /> Billing Party Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />ZIP <br /> Billing Party Facility Owner Property Owner Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />DATE: <br /> OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br />R <br />Date PE Fee <br /> Cash Check* <br />Rev 07/10/2024 <br />5 <br />£3 Facility Owner <br />I <br />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <br />^PROPERTY (gUSINESS OWfj|fifr <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 />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 apptiotion 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. (( J G f C— <br />APPLICANT'S SIGNATURE: DATE: ~ P - ocO. j <br />Asstgnetl To <br />Type of Service <br />Requested <br />Comments <br />Email ^7 <br />^Vacility Contact ' — <br />First Name <br />Address <br />CxO <br />Title <br />^^6 , <br />Phone <br />City <br />14 £86 lb <br />Phone Phonejpq- %J4. Gsjx 40% W <br />s,a’tA <br />Last name <br />EmailvxsfrX.. <br /> Facility Contact p . Contractor <br />Phone Phone <br />^144^4 <br />City <br />City <br />'WVlC) <br />First Ngme <br />&UAK) <br />Address State , <br />c A <br />\C%M <br />5l,eTrg6 q 41^ U <br />Supervisor District <br />I infcerl fiA in <br />_________yrs ooo~n<c0i <br /> connro..^*