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❑ New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Former Nestle USA site <br /> Site Address City State ZIP <br /> 230 Industrial Ave Ripon CA 95366 <br /> APN Supervisor District <br /> 25929004,25938001 <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel 0 Other <br /> Requested Operating Permit <br /> Comments <br /> Workplan Review for 2 offsite piezometers located at Ripon High School(301 N Acacia Ave) <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck I I �:E <br /> Contact Types 0 Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner 0 Contractor ❑Architect <br /> required <br /> IR Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> Haley&Aldrich, Incl. <br /> First Name Last name If contractor,indicate type and license number <br /> Cameron Paez <br /> Address City State ZI P <br /> 426 17th St Suite 700 Oakland CA 94612 <br /> Phone Phone Email <br /> 949-554-4566 cpaez@haleyaldrich.coryi <br /> Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner H Contractor ❑Architect <br /> Geocentric Drilling, Inc. <br /> 1196-304-2665 <br /> rst Name Last name If contractor,indicate type and license number <br /> ike Cramer C-57 Driller-1073146 <br /> dress City State ZIP 95691 <br /> 80 S River Rd Suite E West Sacramento CAone Phone Email mike@geocentricdrilling com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ftProperty Ownere ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Ripon Unified School District <br /> Address City State ZIP <br /> 364 N Acacia Ave Ripon CA 95663 <br /> Phone Phone Email <br /> 209-599-2131 <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 th' tion and t t work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERA s. <br /> APPLICANT'S SIGNATURE: DATE: 7/11/25 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR ANAGER 0 OTHER AUTHORIZED AGENT Haley&Aldrich <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 /> Accepte y _ Assigned T Linked FA ID <br /> Date PE Fee 7 Record Number <br /> Z i-qv 3 5 � Ras 5 <br /> ❑Cash ❑Check# Confirmation# Z LI Payment <br /> Received By <br /> Rev 07/10/2024 <br />