Laserfiche WebLink
f • <br /> New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address 7Cityf State ZIP q 3 Oy <br /> APN Supervisor District <br /> ,X'>9-600-loo-4o - <br /> Type of Service WApplication for 13Consultation ❑Change of Owner fiVepairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck I <br /> Contact Types J&Billing Party Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> $Filling Party J3 Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name It contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> C3 Blfling Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor O 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 JEF/v <br /> First Name Last name If contractor,Indicate type and license number VF <br /> D <br /> Address <br /> City Slate ZIP S 3 Z�Zy <br /> 7 <br /> Phone Phone Email0I NrY <br /> BILLING ACKNOWLEDGEMENT.1,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project or <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 IOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. j <br /> APPLICANT'S SIGNATURE: DATE: O— <br /> PROPERTY/ U INESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign Is required <br /> erator of the property located at the above site address,hereby au[honre the <br /> AUTHORIZATION TO RELEASE INFORMATION:when applicable,I,the owner or op <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 /> Accepted ByVidal i edraza Assigned To Kadeanne Linhares Linked FA W <br /> Fee ec rd Number <br /> 24 <br /> Date 10-24- PE 1601 516 ( <br /> P 12/2024 / payment 190261283 <br />