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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Olin Chlor Alkali <br /> Site Address City State ZIP <br /> 26700 South Banta Road Tracy CA 95304 <br /> APN Supervisor District <br /> 252-150-080-000 5 <br /> Type of Service ❑Application for onsultation ❑Change of Owner ❑Repairs or Remodel ®Other <br /> Requested Operating Permit <br /> Comments <br /> iv yr% �l�Y,u� �Zr-v'=-� 5✓1-� tat-✓�L`��.�L� L► <br /> VIN <br /> If mobile food truck or License Plate Number <br /> pumpertruck -7 <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party ®Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Dane Grimshaw <br /> Address City State ZI P <br /> 490 Stuart Road NE Cleveland TN 37312 <br /> Phone Phone Email <br /> (408)599-4030 DRGrimshaw@olin.com <br /> ®Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ®Contractor(Consultant) ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Jessica Ramirez <br /> Address City State ZIP <br /> 1111 Broadway,6th Floor Oakland CA 94607 <br /> Phone Phone Email <br /> (510)285-2682 JRamirez@geosyntec.com <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 /> 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 b"rformed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 4/28/202S <br /> ❑PROPERTY/BUSINESS OWNER C�1)1 <br /> PERATOR/MANAGER ®OTHER AUTHORIZED AGENT Jessica Ramirez,senior Engineer,Geosyntec Consultants <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 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 /> Accepted By Assigned ' , Linked FA v t 1 <br /> Date, i L � � 7 PE �!, b Z Fee i ` c Record N�ber <br /> ❑Cash` ❑Check# > l bConfirmation# p 11 R l Payment <br /> 2 p q t 5 Received By <br /> Rev 07/10/2024 <br />