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San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Na & .r <br /> rna <br /> Site Ad s y y^— icy Sta A Z � <br /> Q� <br /> APN Supervisor District <br /> Type o€5ervice pplication for El Consultation ElChange of Owner ❑Repairs or Remodel ❑Other <br /> Requested prating Permit <br /> Comments <br /> If mobile food truck or License Plate Numb )', V1N <br /> pumper truck f `r � , OR <br /> Contact Types AN Billing Party JIM Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required I <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Na me If contractor,indicate type and license number <br /> C& rz(a <br /> Ad s G St ZIP l'^ <br /> Il .41 .� <br /> Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name Ifcontractor,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 <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this projector activity will be billed tome or my b siness as identified on this <br /> form. <br /> I also certify that I have prepared this applicatio and that t work to be performed will be done in accordance with I SAN JO UIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT PAY�8N <br /> Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required C,��YZ <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,herM, thgrjye the <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENWRONMENTA I L < <br /> DEPARTMENT as soon as it is available and at the same time it is provided tome or my representative. SAID jr,. <br /> N N <br /> Accepted By t.Z Assigned To �� linked FA I D 1fi DZRA N <br /> bate PE Fee Record Number <br />