Laserfiche WebLink
❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name — <br /> Site Address City State ZIP <br /> 10 env e e t-% PA V S� c k 10 <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ©Other <br /> Requested Operating Permit <br /> Comments <br /> L L -Co ,k <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> filling Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name MCI <br /> If contractor,indicate type and license number <br /> Address City State ZIP <br /> e INV Q cc V,I C t, c <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner C1 Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <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 chi ation and t t the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDER ws. <br /> PPLICANT'S SIGNATU cz— ' ATE: <br /> �4f'ejv <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED <br /> A ORIZED AGENT � � <br /> VJ <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title cjel <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at the above site addrg her y authorize e <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY NVIR4N [ S <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. a""N J <br /> Accepted By Assigned To Linked FA ID <br /> ry p�MF,yt�Niy <br /> Date `Z PE ^ Fee gin C) Record b <br /> t�unl <br /> Payment <br /> Cash4F3��r ❑Check d ❑Confirmation fl Received By <br /> Rev 07/10/2024 <br />