Laserfiche WebLink
Facility Name <br />ZIPStateSite Address <br /> Other Change of OwnerConsultation <br /> Architect Property Owner Contractor’QTacility Owner Facility Contact Billing Party <br />Bkfaciiity Owner Contractor Property Owner Architect Facility Contact Billing Party <br />If contractor. Indicate type and license number <br />rn^/zz-A-Address <br />Phone <br /> Architect Contractor Property Owner Billing Party <br />If contractor, indicate type and license number <br />Al? fa <br /> □ Architect Contractor Facility Contact Facility Owner <br />If contractor, indicate type and license number <br />ZIP <br /> OTHER AUTHORIZED AGENTOPERATOR/MANAGER PROPERTY / BUSINESS OWNER <br />Linked FA IDAssigned ToAccepted By 'P <br />FeePE <br />64 iog^zogs^, /' <br />Contact Types <br />required <br />z2/A/t7 <br />VIN / / <br />^CA- <br />nwL-CUkn_____ <br />business owner, operator or authorhr^ agent olsame, acknowledge that all site and/or project <br />or <br />’j^tacility Contact <br />Phone Email <br />State AC.A___ <br />rcmari/eM . Com <br /> Billing Party <br />I First Hame •I Th riA <br />MTiO <br />Rhone <br />2 ___ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or author^ agent oTsame, 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 <br />I al^ certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNT^gQgjV/PH <br />Standards, STATE and FEDERAL laws. , ' “Cl / <br /> APPLICANT'S SIGNATURE: ---------------------------------------------- DATE: 09/09/25---------------------------------- <br />Title SAf^J^AQuiH Q <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 <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTALTCflWTMEtf ■ <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. --------------------------------------------------- ------------- <br />_______ _ ___________ <br />b raHspAT) b hj Cj chn <br /> Property Owner <br />_________ <br />roate . / P[ 4/1^242 <br />San Joaquin County Environmental Health Department <br />Application Form <br />Pfacz Cbcireh C&hye Church) <br /> <br />Supervisor District ,APN S-r------- <br />Type of Service C " ,. “ <br />Requested <br />Comments j / Ia <br />'Co/T&M <br />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <br />io>spfch>o <br />License Plate Nui/ber <br />First Name . <br />T11L- <br />Phone . -------- <br />ZIP7533 <br />- _____________r. t—____ ___ _____________ <br />kjs/rioh 5- ^I'C^rur) <br /> Repairs or Remodel <br />First Name i ) J w via <br />H Phone T Email / J <br />2Z>7- 2.371--/57/ <br /> Facility Owner