Laserfiche WebLink
* <br /> New Facility <br />San Joaquin County Environmental Health Department <br />Facility Name <br />APN <br />SoChange of Owner Consultation Repairs or Remodel Other <br />-VIN O <br />. com <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />Ef Billing Party S'Facility Owner B'Facility Contact Property Owner Contractor Architect <br />■fiuiiiUei* <br />Phone Email <br /> Facility Owner Facility Contact Property Owner Contractor Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address City State ZIP <br />Phone EmailPhone <br /> Billing Party Facility Owner Facility Contact Property Owner Contracl <br />First Name Last name <br />Address City State <br />Phone EmailPhone <br />DATE: <br /> PROPERTY / BUSINESS OWNER <br />Title <br />Assigned ToAccepted By <br /> Cash Check tt <br />Rev 07/10/2024 <br />Contact Types <br />required <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 />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <br />City State <br />ZIP <br />A- <br />StateGA <br />\aI <br />If contractor, indicate type and license <br />Type of Service <br />Requested <br />Comments <br />License Plate Number <br />Payment <br />Received By <br />Existing Facility <br />\! Pedraza <br />PEl^03 <br />______TBP <br />^175Date <br />G - | I ~ <br />______Application Form <br />On HC <br />Site Address 71 " . <br />Supervisor District <br />Confirmation W <br />Z|Px-^^>6 <br />First Nameukinpvwp.T______ <br />Address I , <br />SHT-i ZftcCAriq <br />Phone Phone chkhi i L <br />ft @ I ■ Gm’ <br /> Billing Party <br />If contractoj^Jt^ r^pe and license number <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, ackr^^f^ge 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. Il <br />I also certify that I have prepared tIns applicdWon an^that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL lawA fZ- / P // C\< 0 111/ <br />APPLICANT'S SIGNATURE: DATE: 0 sZ. <br />/ □ OPERATOR / MANAGER □ OTHER AUTHORIZED AGENT