COMPLIANCE INFO_2026 - Laserfiche WebLink

Home Browse Search

O New FacilityExisting Facility � (needs SR##) San Joaquin County Environmental Health Department Application Form Facility Name A Contact Types 6t1 Billing Part y ❑Facility Owner ®Facility Contact ❑Property Owner Site Address7 V� l required City State C Address ZIP c State oh Last name t u -, 4 ZIP" S 649 APN City�t O � Supervisor District ZZ10p Phone Phone Email Phone Phone Email S OL )559St- Woo S.ratn •c'j o„"t o k . Co PLq Type of Service ❑Application for ❑ Consultation ❑ Change of Owner epairs or Remodel ❑ Other Requested Operating Per 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 Comments y� J o / , / I re lQ C'z f LL^e l 9) e'xl.S "Ij %I ,p i2'$S �l c ✓1C. ` vV t4a4 �J 'NJ ` y 1 r/ ti VkC°4J� Cry c� If mobile food truck or License Plate Number VIN IF pumper truck Billing Party Facility Owner 11 Facility Contact ❑Property Owner CW y ❑Facility Owner ®Facility Contact ❑Property Owner ®Contractor ®Requester required Last name If contractor, indicate type and license number Address City State ❑Billing Party ❑Facility Owner ❑Facility Contact Ell Property Owner L1 Contractor 13 Architect rrFreetar ❑ Architect First Name Last name If contractor, indicate type and license number Address City State First Name Last name If contractor, indicate type and license number Email ZIP" Payment Received By Address Co to n � 1� WS�3G' City�t O � State CAW ZZ10p Phone Phone Email Phone Phone Email S OL )559St- Woo S.ratn •c'j o„"t o k . Co PLq Cl Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑ Contractor First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email ZIP" Payment Received By Accepted By n Assigned To Linked FA ID ��Yll �1�St7�'ji5� f7h qLJI ❑Architect First Name Last name If contractor, indicate type and license number Address City ❑ Check N State ZIP" Payment Received By ` Phone Phone Email y�l rhR4N �N C BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or projec specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity 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 be performed will be done in accordance Standards, STATE and FEDERAL laws, APPLICANT'S SIGNATURE: L DATE: with all SAN JOAQUIN COUNTY Ordinance Codes, PROPERTY / BUSINESS OWNER 11OPERATOR / MANAGER ❑ OTHER AUTHORIZED AGENT F Title 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 DEPARTMENT as soon as it is available and at the same time 1t is provided to the or my representative. Rev 07/10/2024 2 of 6 1"af'C.rr� rfq11 Record Number Cash ❑ Check N Confirmation N /� Payment Received By ` Rev 07/10/2024 2 of 6 1"af'C.rr�