COMPLIANCE INFO_2024 - Laserfiche WebLink

Home Browse Search

□ Existing Facility San Joaquin County Environmental Health Department Site Address APN □ Consultation □ Change of Owner □ Repairs or Remodel □ Other □ Billing Party □ Facility Owner □ Property Owner □ Contractor □ Architect [i Facility ContactFacility Owner □ Property Owner □ Contractor □ Architect If contractor, indicate type and license numberLast name s Address State ZIP □ Billing Party □ Facility Owner □ Property Owner □ Contractor □ Architect First Name If contractor, indicate type and license numberLast name Address City State ZIP Phone Phone Email □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor First Name Last name Address City State Phone EmailPhone □ PROPERTY / BUSINESS OWNER □ 01 IATOR / MANAGER □ OTHER AUTHORIZED AGENT Title Linked FA ID PE □ Confirmation it□ Cash Rev 07/10/2024 If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, ------------------ -------------------------------- DATE: /"/ ’S'] <z? City Supervisor District Contact Types required Billing Party Record Number Payment Received By< New Facility □ Architect If contractor, indicate type ai^liJ’Q^e ____,a ____________________________________________________________________________________ BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site aro^^bject specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified orrmis form. i I also certify that I have prepared tWis application ai Standards, STATE and FEDERAkWr. APPLICANT'S SIGNATURE/^ Assigned Tq Fee^/lZ.0O> Application Form //az First Name i Phone Email □ Facility Contact Accep,e^efP C. ZIP^x D/z/fz>| 2-to4 6 Check n Type of Service Requested Comments r / / ______SwlUSlMiS If mobile food truck or pumper truck s<3,e C4 ■ Application for Operating Permit approved /efkr. License Plate Nu^^^^ □ Facility Contact