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❑ New Facility 0 Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> California Tank Lines <br /> Site Address City State CA ZIP <br /> 3105 S. El Dorado Street Stockton 95206 <br /> APN Supervisor District <br /> 619-280-5900 District 1 <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel XOther <br /> Requested Operating Permit <br /> COmmantc <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Facility Owner ❑Facility Contact ❑Property Owner Cl Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Innovative Environmental Solutions (IE ) Consultant, License#962676 <br /> Address City State ZI P <br /> 839 Second Street Ste. 2 Encinitas CA 92024 <br /> Phone Phone Email <br /> (760)632-2330 mdavis iesconsul ants.com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner 0 Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> same as above <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party 0 Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> El Dorado Land Holdings LLC <br /> Address City State ZI P <br /> P.O. Box 6632 Stockton CA 95206 <br /> Phone Phone Email <br /> (209)466-3554 ext 322 <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 pe orm will be done In accordance wit all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> � i c c i`✓y E lS l`S <br /> APPLICANT'S SIGNATURE: ti�-�' DATE: <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT Imo/c'5 <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 To Linked FA ID <br /> i <br /> C 'j <br /> Date Fee Record Number <br /> � (2 LtiD 3Ra50139 <br /> E. Z Payment <br /> ❑Cash ❑Check# ClLonfirmation# 7.u-1 Received By <br /> Rev 07/10/2024 <br />