Laserfiche WebLink
y <br /> New Facility Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />ZIP <br /> Consultation Change of Owner Repairs or Remodel Other <br /> Facility Owner Facility Contact Property Owner Contractor Architect <br />J^Billing Party .^Facility Owner -(facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license number <br />Email <br /> Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br /> Facility Owner Facility Contact Property Owner Billing Party <br />First Name Last name <br />City StateAddress <br />Phone EmailPhone <br /> OPERATOR/MANAGER PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA IDAccepted By <br />Date <br /> Confirmation it Cash <br />Rev 07/10/2024 <br />aii'iiiui iintdiir <br /> Application for <br />Operating Permit <br />ZIP <br />Contact Types <br />required <br />lie and/or project <br />Jjtlfled on this <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 />State <br />State <br />--r fs /-( <br />Supervisor District <br />Type of Service <br />Requested <br />Comments <br />LastnameWk, <br />Check it <br />■f < <br />VIN <br />vk FaciUtY-htarRc j <br />APN <br />First Name <br />]/NCgN~_______________ <br />Address r T <br /> Billing Party <br />City, \ <br />______________X DATE: <br /> OTHER AUTHORIZED AGENT <br />Record Number <br />3(2114- <br />Payment <br />Received By ( k <br />Fee .g m <br />CQ <br />, TpE <br />Assigned To <br />If mobile food truck or License Plate Number <br />pumper truck ' <br /> Billing Party <br /> Contractor _ I Architect <br />If contractor, ncWif®^number <br />—H <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, ackn’o^lt^^i'yi^ie ; <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my busine/sTOity <br />form. <br />I also certify that I have prepared this applicationjnd that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />^Standards, STATE and FEDERAL laws. / \ i — / ■-? S' <br />^APPLICANT'S SIGNATURE: // ^^DATE: Zy ' y/ ________