Laserfiche WebLink
❑ New Facility [ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name N (I <br /> Site Address n City L State ZIP <br /> U ti l\ <br /> Al Supervisor District <br /> Type of Service ❑Application for ❑Consultation Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> MF �: <br /> If mobile food truck or License Plate Number VINr J/ <br /> pumper truck rT <br /> l I f <br /> ❑Contractor Q Architect <br /> Contact Types ❑Billing Party El Facility Owner ❑Facility Contact ElProperty Owner <br /> required <br /> 0 Billing Party Facility Owner Facility Contact ❑Property Owner ❑Contractor Q Architect <br /> First Name last nam If contractor,indicate type and license number <br /> r "1iJ <br /> Address city State ZIP <br /> Phone Phone mail <br /> a 5A7 -7 <br /> �b <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ElProperty Owner ❑Contractor Q 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 <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 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 hat the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY PAN071 <br /> Standards,STATE and FEDERAL laws. R�►/' <br /> APPLICANT'S SIGNATURE: pA7E: E�V�D <br /> Q PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> TitleSAN <br /> if APPLICANT is not the BILLING PARTY,proof of authorization to sign is required � �Q�Q(Jf/y <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site adgill <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONM � 1[ <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. FONT <br /> Accepted By Assigned To Linked FA ID <br /> 3e. f C - '1-rC�r\cisC.0 R. ifAQKbIil <br /> Date PE fe <br /> Record Number <br /> �1V�t2� ti�m3 ��z ® �a SP- 2-L4mm4gm <br /> Payment <br /> lidJ Cash 1 + ❑Check k D Confirmation q Received B <br /> Rev07/10/2024 Rj1���(/� , /t� <br />