Laserfiche WebLink
❑ New Facility ?I-Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name S � ke- a ,V <br /> Site Address City State ZIP <br /> 110 E7 'Tu r wir 0- ko AD -;2 f� <br /> APN Supervisor District <br /> a 0qI? c, c <br /> Type of Service ❑Application for Ionsultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments [4-p I a <br /> If mobile food truck or License Plate Number llIN <br /> pumper truck <br /> Contact Types ❑Selling Party 0 Facility Owner ❑Facility Contact - b Property Owner ractor ❑Architect <br /> required <br /> Billing Party ❑Facility Owner ❑Facility Contact Property Owner ❑Contractor ❑Architect <br /> First Name Last n e If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email Ld <br /> 9;2.f--?76 & 4-3 1 4M I, n <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 /> z b� Gal-to <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate typo 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 an this <br /> form. <br /> I also certifythat I have prepared this application and that the work to be performed will be done in accordance with all SAN JQAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. f <br /> APPLICANT'S SIG NATURE: -�c�" DATE: /�t S~ <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ]THER AUTHORIZED AGENTrJN_C1PAL <br /> Title <br /> If APPLICANT Is not the BILLING PARTY,proof of authorization to sign Is required <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owneror operator of the property located at the above site address,hereby authorize the <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> Accepted By Assigned To Linked FA ID <br /> t7a P -t4L Fee Record NumberI <br /> L rCDP Payment <br /> 0Cosh C CCheck JI ;z {� ❑Confirmation n Received By <br /> Rev 07/10/2024 <br />