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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> City of Stockton Wastewater Recovery Center <br /> Site Address City State ZIP <br /> 2500 Navy Drive Stockton CA 95206 <br /> APN Supervisor District <br /> 163-330-03 <br /> Type of Service ❑Application for IN Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit Environmental <br /> Comments <br /> Application form in support of a site mitigation well&boring permit application for destruction of monitoring wells J_�Y C4 6 <br /> If mobile food truck or License Plate Number 7pumper truck <br /> P� 10641ng Party, LI'X�ciIlty.Cohtact. Ll Prppetty Owner CJ Gontrador "' ' ' Gl Architect.j�r it <br /> � iF*�t• tJ.s. r J � <br /> .itGld�sP`-,, j <br /> i&Bllling Party IN Facility Owner IM FacllltyContact IN Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> CITY OF STOCKTON—ATTN:All Gharegozloo <br /> Address city 2500 Navy Drive Stockton State <br /> a ZIP 95206 <br /> Phone Phone Email <br /> (209)937-8787 IAII.gharegozloo@stocktonc i.gov <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner IN Contractor ❑Architect <br /> First Name Last name If contractor,Indicate type and license number <br /> CONDOR EARTH-ATTN:Casey Kipf CHG#1011 <br /> Address City State ZIP <br /> 188 Frank West Circle,Suite I Stockton CA 95206 <br /> Phone Phone Email <br /> (209)969-2034 ckipf@condorearth.com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact Property Owner Contractor ❑Architect <br /> T__ <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 applicationVadat the work to a rformed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. e <br /> APPLICANT'S SIGNATURE: 07;- DATE: <br /> All Gharegozloo,Deputy MUD D o ring and Department Services / <br /> ❑PROPERTY/BUSINESS OWNER 91OPERATOR GER ❑OTHER AUTHORIZED AGENT <br /> �/�v <br /> '�P 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 on as h available and at the same time it Is provided to me or my revresentative, <br /> tx7 <br /> {fls+fsf�jtedTO "r :e�° �se�•/��kV" 11F.�}IQ, �` �. � .Z � I i�� }�Hf: <br /> x t ri. Yam.r ina A^irS d` r': <br /> 4� a•I Fj v r�7•I Fe t.�� e-' t i�A I� `- a r. ��+ <br /> WV <br /> � <br /> W��� ,. h ;.','6�YYi ..?•'�3.1 i di#�"l4�:t�: � `::4r,�'�I t:.. - r �d g��{{•;x.*7�'.9a><� , <br /> ' n.3 Cf)gdkk 5afcr. �G .r Cogfirmation# p' i �3Jrk� i Y ��"'A,f <br /> .�-. a a wpw S �y..• :� .. htu .1✓,�..r .Received By ar ax4„u Ft <br /> Rev 07/10/2024 :Z ( 6 6,S> L 13 <br />