Laserfiche WebLink
.2 2!5 LE® <br /> V C—�M ❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Facility Name Application Form <br /> Site Address <br /> 350 CRITCHETT AVE city State <br /> TRACY CA Z" 95304 <br /> APN Superviso District <br /> 241-110-400 <br /> Type of Service TRACY <br /> for ❑Consultation <br /> Requested ❑Change of Owner ❑Repairs or Remodel Other <br /> Operating Permit <br /> Comments <br /> SOILS SUITABILITY/NITRATE LOADING STUDY <br /> If mobile food truck or License Plate Number <br /> pumper truck VIN <br /> Contact Types 19 Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor <br /> required ❑Architect <br /> ®Billing Party ❑Facility Owner ❑Facilit:Co ta:t- <br /> �OP fyOer Contractor <br /> ❑Architect <br /> First Name Last name <br /> If contractor,indicate type and license number <br /> ROBERT SMITH <br /> Address Cit <br /> PO BOX 22748 SACRAMENTO state CA ZIP <br /> Phone Phone Email 95822 <br /> 916-229-2424 CCPS.RLS@GMAIL.COM <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 ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate ty e <br /> 1 <br /> Address City State r /1P <br /> /' D <br /> Phone Phone <br /> ic Qui <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge ioep r4ttoject <br /> spe--__ , _= , _yiAL HEALTH DEPARTMENT hourly charges associated with this projector activity will be billed tome or my business as i7eftVftfs <br /> fc— <br /> I a s_ ;.=orepared this application and that the work to erf med will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> AppL res,STAT; a.-4 FEDERAL laws <br /> pppll['ANf^SSa6MA7URE. DATE: 2/24/26 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ®OTHER AUTHORIZED AGENT AGENT <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 /> t,- 1 avec <br /> Date r PE Fee Record Number <br /> a y LY �t �•7��•d� <br /> _ .2I�32G33� Payment <br /> ❑Cash 11 Check# Confirmation# Received By <br /> Rev 07/10/2024 <br />