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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name OXYCHEM STOCKTON <br /> Site Address 1904 West Charter Way Stockton State California ZIP 95206 <br /> APN 163-020-41 Supervisor District <br /> Type of Service ❑Application for F2 Consultation ❑ Change of Owner ❑ Repairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> Comments <br /> Consultation for review of boring permit application and related documents <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types FY) Billing Party ❑ Facility Owner ❑ Facility Contact (_ Property Owner ElContractor El Architect <br /> required <br /> Ili[Billing Party ElFacility Owner ElFacility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> Ron Gestler <br /> Address City State ZIP <br /> 1340 Treat Boulevard,Suite 208 Walnut Creek CA 94597 <br /> Phone Phone Email <br /> 925 278 8688 rgestler@geosyntec.com Geosyntec Consultants, In . <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact 0 Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> Lisa Wasl<om <br /> Address 5 Greenway Plaza,Suite 110 City <br /> Houston State Tx ZIP 77046 <br /> Phone Phone Email <br /> 713 SS2 8765 lisa_waskom@oxy.com Glenn Springs Holdings, Ir c, <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <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 ass ciated 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 applica ' an th e w to e performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: August 15,2024 <br /> ❑ PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER Cl OTHER AUTHORIZED AGENT Project Director <br /> ie <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 ® WAssigned To �, A ) Linked FA ID OIL C1FA Q O 14 <br /> ! f ff <br /> Date (� PE Fee Record Number (� , (/1 o <br /> f� <br /> 7 K <br /> ❑ Cash ❑ Check# gkonfirmation# , 31S PaymentC <br /> Received By <br /> Rev 07/10/2024 Pet) I-Tc— <br />