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❑ New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Central Plume Source Area- Lodi Central Plume <br /> Site Address City State ZIP <br /> 221 W. Pine St Lodi CA 95240 <br /> APN Supervisor District <br /> Type of Service ❑Application for 0 Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments ' n <br /> WP review for Site Mitigation crr r'" G (Vr c <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 /> B Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> VARINDER OBEROI <br /> Address City State ZIP <br /> 581 MONTEGO TERRACE SUNNYVALE CA 94089 <br /> Phone Phone Email <br /> 415-424-3009 vsoberoi@cht-weter.net <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ®Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> VARINDER OBEROI Consultant- PE C69037 <br /> Address City State ZIP <br /> 581 MONTEGO TERRACE SUNNYVALE CA 94089 <br /> Phone Phone Email <br /> 415-424-3009 <br /> ❑Billing Party ❑Facility Owner ®Facility Contact _T❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Andrew Richle <br /> Address City State ZIP <br /> 1331 S. Ham Lane Lodi CA 95242 <br /> Phone Phone Email <br /> 209-333-6800 1 arichle@lodi.gov <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 a d that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. 4/1/2025 <br /> APPLICANT'S SIGNATURE: DATE: <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ®OTHER AUTHORIZED AGENT Consultant <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 o I Linked FA ID <br /> Date PE C1 u� Fee v� Record Numbe9 R a 5®y)9 <br /> l Z _1 <br /> Payment <br /> ❑Cash ❑Check# Confirmation# (CA 6t U} <br /> Received By <br /> Rev 07/10/2024 <br />