COMPLIANCE INFO_2025 - Laserfiche WebLink

Home Browse Search

¥'□ New Facility San Joaquin County Environmental Health Department APN □ Change of Owner □ Repairs or Remodel'Consultation □ Other License Plate Number □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect □ Property Owner □ Contractor □ Architect If contractor, indicate type and license number □ Property Owner □ Contractor □ Architect□ Billing Party □ Facility Owner □ Facility Contact First Name Last name Address City State EmailPhonePhone □ Contractor□ Facility Contact □ Property Owner□ Facility Owner□ Billing Party Last nameFirst Name ZIPCityStateAddress EmailPhonePhone lica'anj C cDATE: □ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGERPROPERTY / BUSINESS OWNER«!>Title Assigned To □ Confirmation # Rev 07/10/2024 Contact Types required If mobile food truck or pumper truck □ Application for Operating Permit BILLING ACKNOWLEDGEMENT: I, the undersigned property, specific ENVIRONMENTAL HEALTH DEPARTfAKW houHy-dl^ form. I also certify that I have prepared thr Standards, STATE and FEDERAL laW^ APPLICANT'S SIGNATURE: <S—■ ZIP at Existing Facility :hat the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, State Type of Service Requested Comments Address c Phone c: M.?T VIN DEPARTMENT as soon as jt is available and at the same time it is provided to me or my represei □(Billing Party I ^Qfecility Owner First Name . idress , t3W LcnZ lone , , „ „ ,PJ»ne 2C^[ MO r Business owner, operator or authorized agent of same, acknowledge that all site and/or project jes associated with this project or activity will be billed to me or my business as identified on this Application Form pert City . PU5 / / /check# If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ttejtive. LinkedFA>^^^^-7 Record NumberSRzscn I _________ Payment lf~r~ Received By q/Z-Lx' ZIP , Fac^tyName Sije Address 3> Date . ) / '—' PE Z □ Cash Fee ....IjSS; S£p 03 2025 If contractor, indicate type ancr SJ Facility Contact 7^ MO Last name mi feWleuiM W ■ ' ' ISS . •'oOQ LahX Supervisor District f