COMPLIANCE INFO_2024 - Laserfiche WebLink

Home Browse Search

❑ New Facility ES Existing Facility- San Joaquin County Environmental Health Department Application Form 05`l3U�52— ,facility Name ��d', a� LA I,r14av> &r'111 Site Address i City State ZIP 1 S. Viper a[.R . Ske. IQQ LoJ CA APN Supervisor District Type of Service ❑Application for ❑Consultation Change of Owner 0 Repairs or Remodel ❑Other Requested Operating Permit Comments If mobile food truck or License Plate Number VIN pumper truck Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor C7 Architect required Billing Party QrFacility Owner ❑Facility Contact -J ❑Property Owner ❑Contractor ❑Architect First Name ku LW Last name S 06,H If contractor,indicate type and license number Address 1l eS cEA1Ti-je Pircfs L A / City InONT (10 State ZIP IS-3,31 Phone 6 Phone Email s�t�}� ❑Billing Party ❑Facility Owner brFacility Contact ❑Property Owner ❑Contractor ❑Architect First Name to Last name V R If contractor,indicate type and license number Address city CFN�ePfQcI'S �� C�t419 State C� ZIP��r��.� Phone b Phone Email o1721 812J ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect First Name Last name If contractor,indicate type and license number Address City State ZIP Phone Phone Email BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project oractivity will be billed to me or my business as identified on this form. I also certify that I have prepared this application and that the work to he performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes; Standards,STATE and FEDERAL lads. / Q, ! , L APPLICANT'S SIGNATURE: Vl1 DATE: 1 2- ~' PA PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT Title 4 If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required 19 / AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,here ice the 7 release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONME�J /fyC DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. f))4 Lf r 7V Accepted By Assigned To Linked FA ID � t��rr Date ZCI PE J(L o g Fee Rec rd Number ❑Cash ❑Check tt ��/C ry��/., Payment �Cvnfirmation q !� J Received By Rev 07/10/2024