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0 Noti:l Facility 3 Existing Facility <br /> San Joaquin Counter Environmental Wealth Department <br /> Application Form <br /> FariII#yNam2 San Joaquin County Sheriffs Ops #1 <br /> Site Address 7000 N Michael: Canlis Blvd city French Camp state CA zip 95231 <br /> MN Supervisor Glstriet <br /> Type of sere 0 Appllcatton for la Cgnsultatlan ❑Change of Owner 0 Repairs nr V Other <br /> Requested Uperatlrlg Pcrmli I I I Remodel <br /> Comments Applylrlg for tempmry clo5wre permit for the diesel to nk whlBe the ga9Dllne tank Is In repair under SR DIC046A <br /> Wntdck�ypes 0IlldinePmrty I ElFaculityOwner ❑Fadilityconwt ❑Property Own@r ❑Contranor 13ArzjhKKt <br /> reguGed <br /> ❑lllWingParty aeilltyowner CI Fa€ilityConrau 0 Property Owner ❑Contractor 1]Arrhltect <br /> FkrstName an Joaquin County Fast name Kimberly Harris If contractor,IndIrate type and fiLMA <br /> nurnber <br /> Address P 0 Box 1810 city Stockton $tale CA p 95201 <br /> Phone Phone Emalikmharr.!@@Qoy.or$ <br /> 209,953.7508 <br /> BII'IngParty ❑FmiIltyOwrre; ❑FadatyCantad DPropertyOwner Contra0w ]Architect <br /> + ti ` <br /> Fled Name Bagley Enterprises Last name If aintractor,Indicate type and license <br /> number <br /> A-774802 <br /> Address 2370 Maggio Cir 94 city Lodi State CA zip 95240 <br /> Phone2093 7.4800 phone Emali Joe@ ba$leyenterprises_com <br /> 5ares@bbgI@yrrltQ Pt.19'S.0DM <br /> 0 Ellfing Party ❑FaClllty O"er ❑FadlYty Contact 17 Property Owner 17 Contractor C7 <br /> First Narnc Lmt name If contramr,lrrdkmt2 type i <br /> number 4� <br /> Adldfess city State <br /> Phone Phdpne EmaYlQ <br /> AILUNG ACKNOWLEDGEMENT:k,the undersigned pFWerly or business owner,operator or RrthorL�ed agent of same,acknowledge that all skte and/or prof <br /> speclfIc ENVIRONMENTAL HEALTH DFPARTtu NT hwriy charges assaclated with this prOK%l or aethMywill he billed to me or my business as Identified an this <br /> kdmm <br /> I also centfy that I have prepared this apPltcatlon and that the wprk to be performed will be done in accordance w1th all SAN J AQUI N COUNTY Ordinance Codes, <br /> Standa rdt STATE end I`EDEM laws. -Ann Narie Ad wafer <br /> APPLICANTS SIGNPTVFI;r: DATE; _41/24/n2S <br /> ❑PROPERTY{4USIIYE.SSOWNER ❑OPERAIiORIMANAGER [a OTHER AUTHORIZED AGE NT _�ntra€tar <br /> Tttle <br /> ON <br /> I f APPLICANT I s Apt the Rl LUM PARTY,proof of authorl;atian it?slgn Ls requlfed <br /> AsUTMDRIZAIIDN TO RELFASE INFORMATION:When apppdabte,k,the owner or operator of Ihj!property lo[ated at the aWw site addrps%hereby aulhorire the <br /> reWase of any and elk results,geotech nlcal data and/or environmertlaE/site assessment inioematlon to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH. <br /> DEPARTMENT as soon as It is avallable and at the same tI me It Is provided to me ar My re reSentatlwe. <br /> Awep# gSSFgn T LlnkedF#ID <br /> 0 <br /> ] 00 7 <br /> Date f LZ FE _ Fee _ Ar� IteCvN fJum h <br /> Rex U6/1�/+~t}24 <br />