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❑ New Facility 9 Existing Facility <br />San Joaquin County Environmental Healt ent <br />Application Form <br />State ZIP <br />Facility Name <br />Greene Brothers Farm, Inc. <br />Site Address <br />city <br />Lockeford <br />CA <br />95237 am <br />12470 Locke Road. STE C <br />Last name <br />If contractor, indicate type and license number <br />Michelle <br />APN <br />Supervisor gistrict <br />Address <br />City <br />Lockeford <br />State CA <br />ZIP 85237 <br />12470 Locke Road. STE C <br />Phone <br />Phone <br />Type of Service <br />❑ Application for <br />❑ Consultation <br />❑ Change of Owner <br />❑ Repairs or Remodel <br />00 Other <br />Requested <br />Operating Permit <br />Permit Review <br />Comments <br />4.^l, ��'���c <br />;:kvlvttt C.�w'.� Zv�w�; r C�c� rL c <br />If mobile food truck or <br />License Plate Number <br />VIN <br />pumper truck <br />Contact Types © Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ contractor ❑ Architect <br />required <br />❑O Billing Party <br />❑ Facility Owner <br />❑ Facility Contact <br />❑ Property Owner <br />❑ Contractor <br />❑ Architect <br />First Name <br />Last name <br />If contractor, indicate type and license number <br />Michelle <br />Johnson <br />State <br />CA <br />Address <br />City <br />Lockeford <br />State CA <br />ZIP 85237 <br />12470 Locke Road. STE C <br />Phone <br />Phone <br />Email <br />925-989-9636 <br />mjjohnson200@aol.com <br />❑� Billing Party <br />❑ Facility Owner <br />❑ Facility Contact <br />❑ Property Owner <br />❑ Contractor <br />❑Architect <br />First Name <br />Last name <br />If contractor, indicate type and license number <br />Mark <br />Greene <br />State <br />CA <br />Address <br />it <br />C&keford <br />a <br />ZIP <br />95237 <br />12470 Locke Road. STE C <br />Phone <br />Phone <br />Email <br />707-972-0011 <br />O Billing Party <br />❑ Facility Owner <br />❑ Facility Contact <br />❑ Property Owner <br />❑ Contractor <br />❑ Architect <br />First Name <br />Last name <br />If contractor, indicate type and license number <br />Address <br />City <br />Lockeford <br />State <br />CA <br />ZIP <br />95237 <br />Phone <br />Phone <br />Email <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all si?Pa nd/tlr�$ILA, <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business asAWT <br />WT ys r� <br />form. 'vim !®��,' <br />I also certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUr Ordinance Code <br />Standards, STATE and FEDERAL laws. (''' + 1 <br />APPLICANT'S SIGNATURE: +=a.oan+.ve.xve+ess•on DATE: nd/iR/7F $ A 2026 <br />rl�i <br />ti,°f� QC,rf� C® <br />❑� PROPERTY /BUSINESS OWNER ❑OPERATOR /MANAGER ❑OTHER AUTHORIZED AGENT e� .. V�% <br />Title L �N DSP ��/rAL <br />If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Q�T <br />AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authoriizW47' <br />release ofany 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 />L- -), <br />Accepted By �V <br />Assigned o. <br />Linked FA ID <br />v0z�L� <br />Dat I / 2 S/ <br />l <br />PE i_,L <br />tom[ <br />Fee 7 <br />Record Number n�`O 210 <br />K V <br />❑ Cash <br />❑Check # <br />Confirmation # 2 �C+ C� J�3�] <br />Payment <br />Received By <br />Rev 07/10/2024 <br />