COMPLIANCE INFO_2025 - Laserfiche WebLink

Home Browse Search

□ New Facility Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name TALOFA ISLAND TREATS Site Address State ZIP 95336CA APN □ Change of Owner □ Repairs or Remodel □ Other□ Consultation N/A □ Contractor □ Architect□ Property Owner□ Facility Owner □ Facility ContactChilling Party Fl Architect□ Property Owner □ Contractor□ Facility Contact□ Facility OwnerChilling Party If contractor, indicate type and license number State ZIPAddress 95336CA □ Architect□ Contractor□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party If contractor, indicate type and license numberLast nameFirst Name ZIPStateCityAddress EmailPhonePhone □ Property Owner□ Facility Contact□ Facility Owner□ Billing Party Last nameFirst Name StateCityAddress EmailPhonePhone DATE: □ OTHER AUTHORIZED AGENT □ OPERATOR / MANAGER[^PROPERTY / BUSINESS OWNER Title Linked FA IDAccepted By □ Check «□ Cash Rev 07/10/2024 PE If APPLICANT is not the BILLING PARTY, proof o* authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: when applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/slte assessment Information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Contact Types required If mobile food truck or pumper truck BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as Identified on this form. I also certify that I have prepared this application and that the^work Standards, STATE and FEDERAt laws/j-Z ^ / ' APPLICANT'S SIGNATURE: ' Phone 209-241-2618 Last name LAUMOLI Record Number Payment Received By Type of Service Requested Comments MN 942 GETTYSBURG ST Phone 209-345-1119 Zip 502 YOSIMITE RD Supervisor District City MANTECA P Application for Operating Permit . k or License Plate __________ □ Contractor - Arcl^c^, If contractor, Indicate type anch^ense'number _________ E tinafraser6211 .- yahoo.com Date - 10^10^ kJT>e performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, _____________ DATE: □ Confirmation # First Name ALEFOSIO Cltv MANTECA