Laserfiche WebLink
❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> 50Ag,K5 0 tN it-e, Ck A� <br /> Site Address ICity State ZIP <br /> 2 o T <br /> a <br /> APN SuperDistrict <br /> - 000 - <br /> 9sa o <br /> v <br /> Type of Service ❑A plication for 21 Consultation ❑Change 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 ffBilling Party ❑Facility Owner VFacility Contact VProperty Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party kFacility Owner Facility Contact VProperty Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> SAM M A Lc. — <br /> Address City State ZIP <br /> 351 1A (3!5r" PLAcje 5. u 9 d 2 <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner HdContractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> 5 E GIS > <br /> Address Cit State ZIP <br /> ( 38l <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicP a ber <br /> C <br /> Address City State ZIP <br /> A <br /> Phone Phone Email SAN <br /> �AQ <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,ackn oWay <br /> d/or project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my busines; on this <br /> form. <br /> I also certify that I have prepared this is tion and t t work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws La <br /> APPLICANT'S SIGNATURE: / DATE: ' <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER �OTHER AUTHORIZED AGENT e V 1 L �fNEF� <br /> Title <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 /> Accepted By Assigned To Linked FA ID <br /> 64-7 '5q6 L, <br /> Date PE Fee Record Nurpbe <br /> / zZ,(.-O 7-- A"716-0o ZfI�V. I102— <br /> ❑Cash Check# 13� ❑ Payment <br /> Confirmation# Received <br /> Rev 07/10/2024 <br />