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0 New Facility Existing Facility <br /> San Joaquin Counter Environmental Health Department <br /> Application Form <br /> Fa0tYName an Joaquin County Sheriffs 0ps#1 <br /> WAddress 7000 n Michael Canlis Blvd city French Camp state CA zrP 95231 <br /> APH superyisar District <br /> Type of Servt€e ra AppllcAtten for r]cwwlwtion 0 C#langE of OMEr 0 Repairs or ❑DOL-1 <br /> Requested Operating Permlt Remodel <br /> Comments Ug]ey Enterprises Is contracted with San icaquln County to repair primary rues leak In:underground storage tank <br /> Contact ram f] kling Party 0 Facility Ow er t:]Favhty contact E7 P""M owner t3 Conractw Architect <br /> mqulred <br /> 0 Rliling Party 7f&dllty Owner adlity Contact d Ptaperty Owner 17 contractor ❑iu�hlte" <br /> FWUNameSan Joaquin County Last name Kimberly Harris Ifcvntrattorrindrratetype and lLwse <br /> ncrmbff <br /> Address P Q Box 1810 city Stockton state CA 7iP 95201 <br /> Phort-e Phone Email kmharri5@5]gar.org <br /> 209.953.7508 <br /> 1111ng Party ❑Facility Owner ❑Faoillty Contact 0 property owner Contractor ❑Afchlbwt <br /> First Name Bag l ey E nterpdSeS 135t name If contractor,Indicate type and likense <br /> number <br /> A-774802 <br /> Address 2370 Maggio Cir#4 city Lodi State Ca Zip 95240 <br /> Phone 2.0`3.367.4800 Phone Emall toe@bagreyentefprises_[om <br /> sa u5L1baSleyenterprIns,vom <br /> 0 Filling Party Q;acllity Owner ❑Fadlity Camt2et Q Prnperty4wner f]cim"etw ❑Architect <br /> First Name tabt name If contractor,Indicate tyifyapd Ikense <br /> number <br /> Address City Stater <br /> Ph"* Phone Ernall �P <br /> 06 <br /> BILLING ACKNOWLEOGEMENT:II,the undersigned property or busIREss owner,operator ar auMorlbad agetlt of sanMr aduloawledRI! <br /> SpktlfirENVI111CMI 1ENTALHEALTHDEPARTMENThourlychargesassoriated with this projnrtorartlwky will beh1HO0meormybu�� + �Iry <br /> farm. kf <br /> I also certify that I have prepared this appllcatirxr and that the work to he perfprrrritl will be done In anrordanoe with all SAH JBAQUI N COLI�iTY Ordinance <br /> Standa rds,STATE and FEDERAL IaW. <br /> APPLICANT"SSIGNATURE,. NaAz�+ W42YA4. DATE, =09VDSf 4. <br /> ❑PROPERTY I BUSINESS OWNER ❑aPF RAToR J mANAGER Rf OTHER AU MORI3ED AGENT Contractor <br /> Title <br /> IF A1541CM4T is not the 1110NIG PAR?'+'.proof of authorfiation to sign Is required <br /> AUTHORIZATION TO RELEASE INFORMATION When appfii;able,I,the owner orcWraEor of the property located at the abawe site address,hereby authorlre khe <br /> release of ar,y and all result€,aeote{hnica1 data andror emdronmental/site assessment Inrormallon to the SAN NOAQUEr+f COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT as soon as it is available and at the same time A is provIdad to me or my representadve. <br /> Acne d Assigned To Linked FA ID <br /> Date � Pf � feP,yr, ,r� Record 14wriber <br /> Rev 06fl212024 {O <br />