Laserfiche WebLink
❑ New Facility Existing Facility: <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> C in <br /> 5ite Address City State ZIP <br /> G CU r L0 <br /> APN Supervisor District <br /> Type of Service ❑Apptication for ❑Consultation hange of Owner 0 Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumpertruck <br /> Contact Types q Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Q Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If Contractor,indicate type and license number <br /> AL I o <br /> Address Ci y Sta�e ZIP <br /> 1-3 VZO/ cli O <br /> Phone Phone Email <br /> Z e C nal <br /> ❑Billing Party 0 Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> A— I <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 ❑Properly Owner ❑Contractor ❑Architect <br /> First dame Last name If co � I ate type and license number <br /> Address City St 1vleo ZIP <br /> Phone Phone Email �V�s <br /> BILLING ACKNOWLEDGEMENT:i,the undersigned property or business owner,operator or authorized agent of same,acknowledge 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. <br /> I also certify that I have prepared this a plication and Pat the work to be performed will be done in accordance wit all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: DATE: (� <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED 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 /> �' Oft L �i ��a1 ' KR 37 G <br /> Date PE Fee Record Number <br /> ❑Cash 1-1 Checkq Confirmation ft L� 3 �1 Payment <br /> Received By CL <br /> Rev 07/10/2024 �F-N/try CD�;L—1 <br />