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0 New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form 2oL) �?,SG, (� <br /> Facility Name <br /> Kautz Row Crops <br /> Site Address City State ZIP 95240 <br /> See Exhibit A Jq4q0Al. ri <br /> Lockeford CA <br /> APN Supervisor District <br /> See Exhibit A <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel 0 Other <br /> Requested Operating Permit Soils Report <br /> Comments <br /> Soils Investigation Report Performed on 10/2/2022 <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 /> e Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Michael Hakeem <br /> Address City State ZIP <br /> 3414 Brookside Road Suite 100 Stockton CA 95219 <br /> Phone Phone Email <br /> 209-474-2800 mhakeem@hemlavF.com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and livens Q@rA <br /> NT <br /> Address City State ZIP D <br /> Phone Phone Email 22 20 4 <br /> BILLING ACKNOWLEDGEMENT:1,the undersigned property or business owner,operator or authorized agent of same,acknowledge that q�i {� tCQ NT y <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this projector activity will be billed tome or my business asifip ics�l Tq <br /> form. RTM NT <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. ���jj�� <br /> APPLICANT'S SIGNATURE: �,/�I f/Asi8 DATE: H/Z /ZOZ4 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER `QS 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 Assigned To Linked FA ID <br /> Date PEFee Record Number <br /> SlJ-24c0>14y <br /> M Payment <br /> ❑Cash ❑Check# — Confirmation q y,� �� Received By <br /> Rev 07/10/2024 <br />