Laserfiche WebLink
New Facility <br />Application Form <br />Facility Name <br />APN <br /> Consultation Change of Owner Repairs or Remodel Other <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />illing Party ETFacility Owner Contractor Architect Facility Contact Property Owner <br />If contractor, indicate type and license number <br />Email <br /> Facility Contact Property Owner Contractor Architect Billing Party Facility Owner <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />EmailPhonePhone <br /> Contractor Facility Contact Property Owner Billing Party Facility Owner <br />First Name Last name <br />Address City State <br />Phone EmailPhone <br />DATE: <br />0<ROPERTY / BUSINESS OWNER OTHER AUTHORIZED AGENT OPERATOR/MANAGER <br />Title <br />Linked FA ID <br />n Confirmation it <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or 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 />Date <br />l-fl?-^ <br /> Cash <br />City ZIPStateon <br />Phone <br />City <br />VIN <br />3^0, A fl 2 <br />Z^jExisting Facility <br />San Joaquin County Environmental Health Department <br />Type of Service <br />Requested <br />Comments <br />State <br />Assigned <br />icens?><0ber <br />— <br />________________________________________________________________ <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 on this <br />form. <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance witlyall SMI JOAQUIN COUNT^rdinance Codes, <br />Standards, STATE and FEDERAL law<^~ // / (=> <br />APPLICANT'S SIGNATURE: DATE: ( (-_— <br />Site Address <br />^^Application for <br />Operating Permit <br />C i <br />k or License Plate Number <br />M uJhfSl (z> <br />0)0^2^ <br />Payment <br />Received By <br />Fee <br />Supervisor District'1 <br />Last name <br />tAOvwv-k A <br />If contractor, indicafe>tj{pe and license <br />___ <br />ZIP <br />First Name <br />____A fA-iScJ <br />Address <br />Phone <br />Accepted By <br />PE <br />^\checklf