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❑ New Facility Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name City Of Lodi Site Address 1331 S Ham Lane city Lodi State CA ZIP 95242 APN Supervisor District 031 - 04-0-5 Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner 0 Repairs or Remodel ❑ Other Requested Operating Permit Comments During annual spill containment testing, spill bucket failed for the 2,000 gallon gasoline tank; need to replace Hardware/0-rings If mobile food truck or License Plate Number VIN pumper truck Contact Types Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect required illing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner CoQntractor ❑ Architect C 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 209.367.4800 Phone Email sales@bagleyenterprises.com ❑ Billing Party ❑ Facility Owner acility Contact ❑ Property Owner ❑ Contractor ❑ Architect First Name Matt Last name Sinclair If contractor, indicate type and license number Address 1331 S Ham Lane City Lodi State CA ZIP 95242 Phone 209.333.6800 Phone 209.269-4923 Email msinclair@lodi.gov ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect First Name Last name If contractor, indicate type a!!—ym#„ _ Address City State Phone Phone Email 2025 A BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge t iwRolvAlpD specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my busm �r�fD form. IW 1 also certify that I have prepare this-ap"p`lication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards, STATE and RE: s y g�APPLICANT'S SIGNATURE: !/ DATE: _9/22/2025 ❑ 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 Byt,%L— Assigned To � Linked FA ID q Dat�M PE^ ^ Fee Record Nuirlber 52 Rev 06/12/2024 ��5�3