Laserfiche WebLink
/New Facility 0 Existing Facility <br /> San Joaquin County Environmental Health Department <br /> s Application Form <br /> Facility Name <br /> a Site Address � L 5tya C KA o v State ZIP'4 y S�� <br /> D S C G t t drn, T C[J <br /> APN Supervisor District <br /> ro n <br /> Type of Service Application for consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> o" Requested Operating Permit <br /> 3 Comments <br /> If <br /> M _ <br /> > pumpe'retruck truck or License Plate Number <br /> r r <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required :1 � <br /> ❑Mlirg Party Facility Owner C Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> 5 � <br /> First Name — Last name If contractor,indicate type and license number <br /> r,� vLG' rd oturc�r rn� vP Go�zq(eL. <br /> g Address CwitXX Stated ZIP <br /> c cASIS s r!t o �,� �Zl` U►� C!T y S 2 d <br /> Phone hone Email <br /> a oq-�f 5-03" <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact —7❑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 IJ Architect <br /> First Name Last name If contractor,Indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <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 an 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 JOAQQUUINN COUNTY OrdinanceCodes, <br /> Standards,STATE T <br /> APPLICANT'S SIGNAURDERA�laws DATE: C r :rKL1S�ISE� <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT R. EIVED <br /> It APPLICANT is not the BILLING PARTY,proof of authorization to sign Is required <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,the owner or operator of the property located at th lie Sjft dd=iereby authorize the <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUI N19 N ENFAL 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 1, U2 Assigned To �[� ,rj „y t� tiHEALTH <br /> EA THDEPARTMENT <br /> Date ( PE Fee ` [4 t/Y Record Number <br /> 3lZ�r <br /> ff Payment <br /> Cash E f ❑Check# ❑Confirmation N Received By <br /> f • <br /> Rev 07/10/2624 <br />