Laserfiche WebLink
New Facility □ Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />c ft <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />Me <br />VIN <br />O'Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />S^Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name Last name If contractor, indicate type and license number <br />Phone <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address City Slate ZIP <br />Phone Phone Email <br />□ Contractor□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner <br />First Name Last name <br />wAddressCityState <br />EmailPhonePhone <br />DATE: <br />□ OPERATOR/MANAGER □ OTHER AUTHORIZED AGENT <br />Title <br />Linked FA IDAssigned ToAcceptedBy L ■ <br />Record Number , _Fee <br />0*1^ <br />□ Confirmation U□ Check U <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <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 />Payment <br />Received B' <br />State <br />ZIP <br />Type of Service <br />Requested <br />Comments <br />7-^1 s pvortiw <br />dress . \ » i <br />Supervisor District <br />Date <br />)(?5h <br />□ Application for <br />Operating Permit <br />License Plate Number <br />I S' <br />Facility Name, <br />Site AddressI____L_ <br />APN <br />Yxz. <br />Phone <br />■2Of|-6T0-S*H <br />Email . . <br />(VloUA________ <br />______SV>ckW r> <br />State <br />Cft <br />PE <br />If contractor, indicate typ? 5r*dfllfgrW|Yt>rjiber <br />--------- <br />s^NjQAr_______________ <br />___________________________________________________________________- <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site^h’^A/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 this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. . /■ l\ I D P} I 'i P'l <br />APPLICANT'S SIGNATURE: X,U^C- I k DATE: X \ I <br />Property / business owner