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❑ New Facility ® Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Lincoln Center <br /> Site Address lemr �A-�- > tn`"� L Aw'4— City Stockton <br /> state CA ZIP95207 <br /> APN Supervisor District <br /> 09741043 2 <br /> Type of Service ❑Application for nsultation ❑Change of Owner ❑Repairs or Remodel a Other <br /> Requested Operating Permit <br /> Comments n <br /> w v-.r Lt -?Lou" w u <br /> If mobile food truck or License Plate Number VI N <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party 0 Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Phil Johnson <br /> Address City State ZI P <br /> 374 Lincoln Center Stockton CA 95207 <br /> Phone Phone Email <br /> 209-478-9200 pjohnson@sims-grupe.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 /> Jamie Purcell Geosyntec Consultants Inc <br /> Address City State Z I P <br /> 3043 Gold Canal Drive, Suite 100 Rancho Cordova CA 95670 <br /> Phone Phone Email <br /> 5307717497 JWPurcell@Geosyntec.com <br /> {a Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name last name If contractor,indicate type and license number <br /> Lincoln Center Environmental Remediation Trust <br /> Address City State ZIP <br /> 3043 Gold Canal Drive, Suite 100, c/o Joseph Niland Rancho Cordova CA 95670 <br /> Phone Phone Email <br /> 5307717497 1 <br /> JWPurcell@Geosyntec.com <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this <br /> form. <br /> I also certify that I have prepared this a lication 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. /V� i 4/17/25 <br /> APPLICANT'S SIGNATURE: DATE: <br /> ❑PROPERTY/BUSINESS OWNER ®OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT Trustee <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 tome or my representative. <br /> Accepted By Assigned To Linked FA ID <br /> Date1 2 /Z 7— PE _ Fee 1 / u� Record Number <br /> vC ( 7 fa sRaS� 1049 <br /> ❑Cash ❑Check# onfirmation# U L C Payment <br /> Received By <br /> Rev 07/10/2024 <br />