Laserfiche WebLink
□ New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Supervisor District 'APN <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />VIN <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />Party □ Facility Owner □ Property Owner □ Contractor:acility Contact □ Architect <br />■ <br />If contractor, indicate type and license numberLast name <br />Address <br />□ Billing Party □ Facility Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address City State ZIP <br />Phone Phone Email <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor <br />First Name Last name <br />Address City State <br />Phone Phone Email <br />DATE: <br />□ OTHER AUTHORIZED AGENT □ OPERATOR / MANAGER <br />Title <br />Accepted By <br />PE 22 <br />□ Check # <br />Rev 07/10/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />□ Application for <br />Operating Permit <br />_____ <br />□ Property Owner <br />StateSite Address <br />5" <br />Type of Service <br />Requested <br />Comments <br />Fee <br />City . <br />State <br />Confirmation fl <br />(3/?,oo k o T <br />_____ Phone <br />First Name. <br />Phone <br />Date I <br />I <br />□ Cash <br />lintedFA'D00l^^ <br />Record Number ,5Ra,50 /<^<?4 <br />Payment <br />Received bJ , <br />ucense Plate Number <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all sitea?Jltjj(^)U)£C <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on <br />form. <br />I also certify that I have prepared this application and that the workjp be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. p ’-I \ Il 3 C” <br />APPLICANT'S SIGNATURE: V DATE: / ' <br />/^PROPERTY / BUSINESS OWNER <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 />ZIP <br />If contractor, indicate type ancWfca.^5,Piimo” / <br />this <br />■S/a/^h <br />citv t _______t m for <br />Email j, i <br />--------------------------------------------r- <br />□ Facility Contact