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❑ New Facility ✓ Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name Sheriffs Operations Ctr#2 — San Joaquin County Site Address 7000 N Michael Canlis Blvd city French Camp state CA ZIP 95231 APN Supervisor District Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner ✓ Repairs or Remodel ❑ Other Requested Operating Permit Comments Replacing overfill valve If mobile food truck or License Plate Number VIN pumper truck Contact Types ❑ Billing Party ❑ Facility Owner acility Contact ❑ Property Contractor ❑ Architect required Owner ✓ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ✓ Contractor ❑ Architect First Name Bagley Enterprises, Inc Last name If contractor, indicate type and license number 774802 -A Address 2370 Maggio Cir #4 City Lodi State CA ZIP 95240 Phone Phone Email 209.367.4800 sales@bagleyenterprises.com ❑ Billing Party ❑ Facility Owner ✓ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect First Name Anthony Last name Haggerty If contractor, indicate type and license number Address 7000 N Michael Canlis Bvld City French Camp State CA ZIP 95231 Phone 209.468.5217 Phone Email ahagarty@slgov.org &/or bbeckman@sjgov.org ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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, Standards, STATE and FEDERAL la s. 'J,r �/ APPLICANT'S SIGNATURE: N�1i 2� �cY� DATE: 12/17/2024 ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑ OTHER AUTHORIZED AGENT Contractor Title If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Accepted By Assigned To Linked FA ID Rev 06/12/2024