Laserfiche WebLink
0 Facility Owner 0 Billing Party <br />First Name <br />Address <br />Phone Phone <br />k)-t <br />re „co c <br />\ <br />0 Billing Party 0 Facility Owner <br />First Name <br />Address <br />Phone Phone <br />2ontractor <br /> 0 Architect <br />)ntractor, indicate type and license number <br />:e ZIP <br />:ontractor Architect <br />CS New Facility 0 Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />/ <br /> <br />5 \ MO 1 SW** LIZ <br />Site Address <br />23056( L-o C_&sa- 6-1 <br />City State <br />CPt <br />ZIP 615 D''k -i-ra <br />APN <br />219q -350 -ND 'OCC <br />Supervisor District <br />— P--0\a21 -1— R,ccxxvx4,-(\ <br />Type of Service le..Application <br />Requested <br />for <br />perating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel El Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />license Plate Number VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact property Owner 0 Contractor 0 Architect <br />El Billing Party 0 Facility Owner 0 Facility Contact )(Property Owner 0 Contractor 0 Architect <br />First Nameizt" wa4:46%, Last name <br />Mai \'LleS <br />If contractor, indicate type and license number <br />Address <br />2- OSAc I--41— Oit5A- CA- <br />CA__ <br />1 irsar_Al <br />State fi <br />(../A- <br />ZIP <br />ct 5 3oq <br />,Phone, <br />(a ) (0 40 -5 31 c m <br />Phone Email , <br />reatccAw616Liesciw,-i\-c„tyrn <br />BILLING ACKNOWLEDGEMENT: I, the undersig <br />specific ENVIRONMENTAL HEALTH DEPARTMEI <br />form. <br />laws. <br />I also certify that I have prepared this a plication and tnat tne work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL <br />APPLICANT'S SIGNATURE: DATE: /Oh <br />PAYME m • intractor, indicate type and licenseRtqc v / ti r) <br />JOvo/CRAT <br />A6jEcA 724 <br />3Num ouNTy <br />ne, acknowledge that all site anabfloieigN iv AL <br />d to me or my business as identified on this RTW ENT <br />ZIP <br />PROPERTY / BUSINESS OWNER CI OPERATOR / MANAGER CI OTHER AUTHORIZED AGENT <br />Title <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 />Accepted By L-\ f\V\o\re C <br />Assigned To L',,-,\r-NcA r -es <br />Linked FA ID <br />Date PE Fee agcgrs1 Number ._ . <br />IA y2LK.D it 61 <br />0 Cash 0 Check #A ConfirmatIon # \ CeJ)C.A 5--+ ,._, -ict 2 _) <br />Payment <br />Received By bpi, <br />K/SOD123 <br />Rev 07/10/2024