BILLING - Laserfiche WebLink

Home Browse Search

/ New Facility ❑ Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name Site AfJtJrglss�' \v l ' ck ` City 1 _` '1 State � ZIPA s^ No APN 1111 1vU Supervisor District wfV�U` (/1 L Type of Service ❑ Application for Consultation ❑ Change of Owner ❑ Repairs or Remodel ❑ Other Requested Operating Permit Comments If mobile food truck or License Plate Number VIN pumper truck Contact Types Billing Party Facility Owner Facility Contact ❑ Property Owner ElContractor ❑ Architect required ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect First Name Last a e 1Qr/ If contractor, indicate type and license number Address „ ^ �4� '� W City 1 � State ZIP_ Phone�� ✓� Phone Email 6 (� 2C�1 ir�l� ir � 0.) I. t ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect First Name Q . Last name If contractor, indicate type and license number V Address City State ZIP Phone Phone Email ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor PAY r��rF�ij�t First Name Last name If contractor, i MM t i j]gjDnumber Address City State OCENVIRT 0 ZIN25 Phone Phone Email SAN JOAQUI COUNTY NTA BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledg r project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. I also certify that I have prepa ed this applic on an that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERA laws. APPLICANT's SIGNATURE: DATE: In 12C ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Title If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Accepted By Assigned To Linked FA ID 66I, mcm Date PE Fee Record Number 17 9 APZSm'Zg2 0 I Payment ❑ Cash ❑ Check# Confirmation# V�,L_/!`/1� 4/„ Received By Rev 07/10/2024