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0 New Facility [3/Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form ?go si-1/1 <br />Facility Name <br />Grocery Outlet <br />Site Address <br />520 S Cherokee Lane Ste #102 <br />City <br />Lodi <br />State <br />California <br />ZIP <br />95240 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />Change of Ownership on 01/14/2025 <br />If mobile food trutk or <br />pumper truck / <br />License Plate Number VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractoi 0 Architect <br />First Name <br />Mikedaleno <br />Last name <br />Harvey <br />If contractor, indicate type and license number <br />Address <br />520 S Cherokee Lane Ste #102 <br />City <br />Lodi <br />State <br />California <br />ZIP <br />95240 <br />Phone <br />209-603-2882 <br />Phone Email <br />cHarvey.mHarvey*gobmio.com <br />0 Billing Party 0 Facility Owner El Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor El 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: <br />specific ENVIRONMENTAL <br />form. <br />I also certify that I have prepared <br />Standards, STATE and FEDERAL <br />0 PROPERTY / BUSINESS <br />If APPLICANT is not the BILLING <br />AUTHORIZATION TO RELEASE <br />release of any and all results, <br />DEPARTMENT as soon as it <br />I, the undersigned property or business owner, operator <br />HEALTH DEPARTMENT hourly charges associated with this <br />this application a d that the work to be performed <br />laws. /Or _........ ___ <br />or authorized agent of same, acknowledge that all site and/or project <br />project or activity will be billed to me or my business as identified on this <br />will be done in accordance with all SAN JOAQUIN COUNTYpaance Codes, <br />DATE: 12/31/2024 49bitets, APPLICANT'S SIGNATURE: <br />OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />PARTY, proof of authorization to sign is required <br />INFORMATION: When applicable, I, the owner or operator of the property located <br />geotechnical data and/or environmental/site assessment information to the SAN <br />is available and at the same time it is provided to me or my representative. <br />f?ces r <br />Owner / Operator <br />Title <br />L't C 3 1 A -..,,, <br />at the above site addr4 Iciesit <br />u <br />thorize <br />JOAQUIN COUNTY EN geot/Nry <br />1-stemt-g.:. <br />Accepted By P Assigned To viz —givr Linked FA ID <br />FA O@ 9.4 3 8 a <br />Date <br />l'31'44— <br />PE 1 <br />1 (190 a <br />Fee ii 4 a (-4-e. Record Number scza 400/ 5 3 <br />CICash 0 Check # 1:4firmation #193687475 <br />Payment <br />Received By <br />Rev 07/10/2024 ,