Laserfiche WebLink
Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberLast name <br />State <br />Ch <br /> Billing Party Property Owner Contractor Facility Owner Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br /> Facility Contact Property Owner Contractor Billing Party Facility Owner <br />First Name Last name <br />CityAddress State <br />Phone Phone Email <br />DATE: <br /> OTHER AUTHORIZED AGENT PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA ID <br />PE <br />Rev 06/12/2024 <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 /> Application for <br />Operating Permit <br />VIN <br />Phone K <br />ZIP <br />^53Z)O <br />that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Ptrrouo______ <br /> CzaAVviy <br />Type of Service <br />Requested <br />Comments <br />c< <br />Email <br />^\OTarrcMpU@<yoai\. com <br /> Facility Contact <br />IE \ Chcfe <br />Supervisor District <br /> OPERATOR / MANAGER <br />.eeep.edB'^^ . <br />P |2 'Z. kiOO '-A Q <br />s'a,cCA <br />Z4 <br />[PE |(P02-______ <br />Ucense Plate Number^ g-j <br />Facility Name^—r— <br />Site Address <br />ZIP^&33O <br />First Name VW_______ <br />Add,e WOO hppkwod <br />Phone <br />If contractor, indicate tyj^e and licffr® <br />__ : <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/of 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 applicatiorj_a <br />Standards, STATE and FEDERAL laws. . - p-' <br />APPLICANT’S SIGNATURE: / <br />Assi8nedTO <br />F“ i