Laserfiche WebLink
f <br />□ New Facility □ Existing Facility <br />San Joaquin County Environmental Health Department <br />Facility Name iOS <br />Site Address City State CA <br />APN <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />^Facility Owner□ Billing Party □ Facility Contact □ Property Owner □ Contractor □ Architect <br />First Name If contractor, indicate type and license numberLast name <br />''^ISZ-D^ <br />Phone <br />□ Billing Party □ Architect□ Facility Owner □ Facility Contact □ Property Owner <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 />□ PROPERTY / BUSINESS OWNER □ OPERATOR/MANAGER □ OTHER AUTHORIZED AGENT <br />Title <br />Linked FA IDAccepted By <br />PE lu>oi <br />□ Check tl □ Confirmation tl <br />Rev 07/10/2024 <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 />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />Phone . <br />Date <br />Type of Service <br />Requested <br />Comments <br />city <br />Application Form <br />£ ^^7 'Zg? <br />Supervisor District <br />□KApplication for <br />Operating Permit <br />uccnseP'atGW^n <br />Assigned To, <br />S 31 <br />StateCA <br />Payment <br />Received By <br />v^NKigM| (p2Z Spo (523^1 <br />wne Email I * z-^ <br />□ Contractor <br />aP^2.15 <br />^Architect <br />_______________________ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that WK/t^sdM^rojecl <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identirfllc^fthis <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 JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: y;