Laserfiche WebLink
❑ New Facility ❑ Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />IN Facility Owner <br />Greene Brothers Farm, Inc <br />❑ Property Owner <br />Site Address <br />City <br />State <br />ZIP <br />12470 Locke Rd <br />Aaron <br />Greene <br />confirmation # Z �j L� _ <br />�' l� <br />APN <br />051-320-12 <br />Supervisor District <br />d <br />State <br />Lockeford <br />CA <br />95237 <br />Type of Service <br />❑ Application for <br />❑ Consultation <br />❑ Change of Owner <br />❑ Repairs or Remodel <br />19 Other <br />Requested <br />Operating Permit <br />707 972-0011 <br />farmacyphactory@gmail.com <br />Comments <br />Cannabis Cultivation Renewal������ <br />If mobile food truck or License Plate Number <br />VIN <br />pumper truck <br />Contact Types ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑Contractor ❑ Architect <br />required <br />❑ Billing Party <br />IN 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 />Aaron <br />Greene <br />confirmation # Z �j L� _ <br />�' l� <br />Address <br />City <br />State <br />ZIP <br />75 N. Main Street #158 <br />Phone <br />925 989-9636 <br />Phone <br />Email <br />doubleagreene@gmail.com <br />Willits <br />CA <br />95490 <br />Iilling Party <br />® Facility Owner <br />❑ Facility Contact <br />❑ Property Owner <br />11Contractor <br />❑ Architect <br />First Name <br />Last name <br />If contractor, indicate type and license number <br />Michelle <br />Johnson <br />confirmation # Z �j L� _ <br />�' l� <br />Address <br />City <br />State <br />ZIP <br />11045 Hills Ranch Rd <br />Phone <br />925 989-9636 <br />Phone <br />1 <br />Email <br />mjjohnson20o@aol.com <br />Mendocino <br />CA <br />95460 <br />❑ Billing Party <br />IN 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 />confirmation # Z �j L� _ <br />�' l� <br />Address <br />City <br />State <br />Zi P <br />75 N. Main Street #158 <br />Phone <br />Phone <br />Email <br />Willits <br />CA <br />95490 <br />707 972-0011 <br />farmacyphactory@gmail.com <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 performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws.c�0/,�rO� 09/15/2025 <br />APPLICANT'S SIGNATURE: YC GG YC J DATE: <br />0 PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT <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 B <br />Assigned To <br />Linked FA ID <br />Da� � ; <br />J <br />PE � � � <br />Fee � � �, <br />Record Number <br />❑ Cash <br />❑ Check # <br />confirmation # Z �j L� _ <br />�' l� <br />Payment <br />Received By <br />Rev 07/10/2024 <br />