Laserfiche WebLink
❑ New Facility t Existing Facility <br /> San Joaquin County Environmental Health Department , Q �ioJ� <br /> Application Form <br /> Facility Name <br /> C G-It G <br /> Site Address City State ZIP <br /> .c-n cx K ZO( <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name / If contractor,indicate type and license number <br /> Address City State ZIP <br /> G3 <br /> Phone Phone Email <br /> noi Qc l . <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑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 ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone -7rEmail <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 application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Or inance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: i c. / F i�r 5 DATE: l I Z I / �� )e ft <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 7 <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site addresty uthoAft <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY EN �(/�� v,- <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. -N� <br /> Accepted By Assigned To Linked FA ID <br /> Date PE Fee Record Number _ <br /> �� <br /> ❑Cash ❑Check# lg Confirmation# 20 Payment <br /> Received By <br /> Rev 07/10/2024 <br />