Laserfiche WebLink
BILLING ACKNOWLEDGEMENT: I, the undersigned pr <br /> <br />rty or usiness owner, operator or authorized agent of same, acknowledge that all site and/or project 0 <br /> <br />specific ENVIRONMENTAL HEALTH DEPARTMEN ourly c s associated with this project or activity will be billed to me or my business as identified on this <br />form. <br />APPLICANT'S SIGNA <br />Standards, STATE an • I • . <br />I also certify that I have prepar.... catio .n,Fr 7c_c_cte wor to be p-' .rmed vi <br />Oro <br />0 PROPERTY / BUSINESS OWNER <br /> <br />0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br /> Title JUN1 7 <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above eAtivd ress, hereb <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNITY <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. JlEALT <br />A e done in accordance with all SA OAQUI COUNTY Ordinance Codes, <br />DATE: <br />DEP <br />rize the <br />UWE& HEALTH <br />AL <br />WA/LIU/WV <br />V d : (g//172 L / <br />San Joaquin County Environmental Health Departme t <br />Application Form & AP2 <br />Far aat re.„4„, . <br />,eJl. sc72---rkk-f6-)0 <br />__. <br />u <br />City 'volivz <br />Grxer4 <br />State <br />F <br />z , .iDA S necivia.,v___ w <br />aii <br />l Site Arrissc57) <br />APN Su i'rvisor District <br />Type of Service <br />Requested <br />Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 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 El Facility Owner 0 Facility Contact tj Property Owner 0 Contractor 0 Architect <br />A Billing Party 14 Facility Owner El Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />410L— <br />LastArn e 1 If contractor, indicate type and license number <br />( . VTI <br />Address 0% ,14__c_ jy. ce'0_,?' City State 0.A._ ZS 3 O <br />330 <br />Iriexi 47/ hone Email <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />0 Billing Party El Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />Accepted By <br />leF c . c. <br />Assigned 'Co 1 cLeckv\Y\fc. <br />Linked FA ID <br />Fil ea) z-.mv-k <br />bate <br />e(01 kkk2-4 <br />PE <br />I(Dt115 <br />Feet Ito 2 Lou ir.-- RThr:572*(2)4m4 <br />$(69/2r pa/1)14 ote4 In'tiCeLf-1-41- 4ht