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0 New Facility ❑ Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Kautz Row Crops <br />Site Address <br />See Exhibit A <br />City <br />Lockeford <br />State <br />CA <br />ZIP <br />95240 <br />APN <br />See Exhibit A <br />Supervisor District <br />Record Number <br />Type of Service <br />Requested <br />❑ Application for <br />Operating Permit <br />❑ Consultation <br />❑ Change of Owner <br />❑ Repairs or Remodel <br />0 Other <br />Soils Report <br />Comments <br />Soils Investigation Report Performed on 10/2/2022 <br />If mobile food truck or <br />pumper truck <br />License Plate Number <br />VIN <br />Contact Types <br />required <br />❑ Billing Party <br />Q Facility Owner <br />❑Facility Con#act <br />❑Property Owner <br />ntractor <br />Q Architect <br />0 Billing Party <br />❑ Facility Owner <br />❑ Facility Contact <br />❑ Property Owner <br />❑ Contractor <br />❑ Architect <br />First Name <br />Michael <br />Last name <br />Hakeem <br />If contractor, indicate type and license number <br />Address <br />3414 Brookside Road Suite 100 <br />City <br />Stockton <br />State <br />CA <br />ZIP <br />95219 <br />Phone <br />209-474-2800 <br />Phone <br />Email <br />mhakeem@hemlav,.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 />Address <br />City <br />State <br />ZIP <br />Phone <br />Phone <br />Email <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 />Address <br />City <br />State <br />ZIP <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 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. p <br />APPLICANT'S SIGNATURE: t(//I,� DATE: 821 2024 <br />❑ PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER Vf OTHER AUTHORIZED AGENT Attorney <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 <br />Assigned To <br />Linked FAIR <br />Date <br />PE <br />Fee <br />Record Number <br />Payment <br />❑ Cash <br />❑ Check # <br />❑ Confirmation # <br />Received By ` <br />Rev 07/10/2024 <br />