SR2400481 - Laserfiche WebLink

Home Browse Search

❑ New Facility ❑ Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name CA 2563 Lathrop Site Address City State ZIP 101 West Lathrop Road Lathrop CA 95330 APN „ Supervisor District Type of Service 0 Application for ❑ Consultation ❑ Change of Owner ❑ Repairs or Remodel ❑ Other Requested Operating Permit Comments If mobile food truck or License Plate Number VIN pumper truck Contact Types 11 Billing Party ❑ Facility Owner ❑ Facility Contact I Property Owner M Contractor ❑ Architect required 0 Billing Party ElFacility Owner ❑ Facility Contact ElProperty Owner M Contractor ElArchitect Partner Engineering -aLtner Enc ineerinq G Science, Inc. ice, Till. First Name Michel Last name He 1 ou If contractor, indicate type and license number Consultant Address 490 43rd Street city Oakland State CAZIP 94609 Phone Phone Email 774-414 -3666 mhelou@pirtneresi . com ❑ Billing Party ❑ Facility Owner ❑ Facility Contact R Property Owner ❑ Contractor ❑ Architect Cardona Family Trust First Name Edward Last name Cardo z a If contractor, indicate type and license number Address 2 604 East Lovelace Road city Manteca State CA ZIP 95336 Phone Phone Email carclozaerterprises202 @gmail . com 209-531- 680 ❑ 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 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 with all SAN JOAQUIN COUNTY Ordinance Codes, Standards,STATE and FEDERAL laws. �,� ; �; APPLICANT'S SIGNATURE: /i�� DATE: 9/ 11 /2 0 2 4 ❑ PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER MOTHER AUTHORIZED AGENT Project Manager 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 it is provided to me or my representative. Accepted By �T, . t Assigned To --�� Linked FA ID A Date 11 1202� PE e9 Fee Record Number 16 O� ❑ Cash ❑ Check# Payment Confirmation# 7 7?ql Received By Rev 07/10/2024