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❑ New Facility X Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name STOCKTON UNIFIED SCHOOL DISTRICT- WEBER INSTITUTE <br /> Site Address City State ZIP <br /> 302 WEST WEBER AVENUE STOCKTON CA 95203 <br /> APN Supervisor District <br /> 137-270-220-000 <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner ❑ Repairs or Remodel B Other <br /> Requested Operating Permit <br /> Comments <br /> UST REMOVAL <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 /> Billing Party Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> VICKIE BRUM <br /> Address City State ZIP <br /> 1944 EL PINAL DRIVE STOCKTON CA 95205 <br /> Phone Phone Email <br /> (209)933-7045, ext. 2341 vbrum@stocktonusd.nel <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> JOSE HERNANDEZ <br /> Address City State ZIP <br /> 1944 EL PINAL DRIVE STOCKTON CA 95205 <br /> Phone Phone Email <br /> (209)933-7045, ext.2353 <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> ROBERT MARTY A-HAZ, C-57 1063765 <br /> Address City State ZIP <br /> 837 SHAW ROAD STOCKTON CA 95215 <br /> Phone Phone Email RECEIVED <br /> MENT <br /> 800-511-9300 rmarty@advancedgeo.biz <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner, operator or authorized agent of same, acknowledg II a nRoject <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identi ie on this <br /> form. SAN JOAQUIN COUNTY <br /> ENVIR�O�N�M1tE��Tnn(_ <br /> I also certify that I have prepared this alp ' do d e work be performed will be done in accordance with all SAN JOAQUIMEGUNrJd}�kMl nonce Codes, <br /> Standards, STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: r/ �2( j?i DATE: 01-22-2025 <br /> ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MA AGER ® OTHER AUTHORIZED AGENT PresidenUAGI-Authorized Agent <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 B Jy C ` ��� �� Assigned To H a z /1 a {T J Linked FA ID ��h®V <br /> Date C�--� PE Fee Gdl \v CAI Record Number l'' <br /> Payment <br /> ❑ Cash EVCheck# Q / ❑ Confirmation # Received By t <br /> Rev 07/10/2024 !, <br />