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® New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form _ <br /> Facility Name <br /> Kenston Farms <br /> Site Address City State ZIP <br /> 400 E Kettleman Lane b}P- 2O Lodi CA 95240 <br /> APN Supervisor District <br /> Type of Service H Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel Cl Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck IN 3173846 13ALACVVFC9NDMV560 <br /> Contact Types 12 Billing Party ❑Facility Owner lfd Facility Contact ❑Property Owner ntractor ❑Architect <br /> required <br /> 12 Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,Indicate type and license number <br /> Sarah Preston <br /> Address City State ZIP <br /> 1053 Commerce Blvd Pelham AL 35124 <br /> Phone Phone Email <br /> 256-404-14.15 support@kenstonfarms.com <br /> ❑Billing Party ❑Facility Owner 0 Facility Contact ❑Property Owner ❑Contractor q Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Devin Byrd <br /> Address City State ZIP <br /> 5045 Whitmire Rd Milton FL 32570 <br /> Phone Phone Email <br /> 334-389-9387 <br /> ❑Billing Party ❑Facility Owner fa Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Karson Pavey <br /> Address City State ZIP <br /> 36 County Road 46 Montevallo AL 35113 <br /> Phone Phone Email <br /> 205-230-7574 <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 application 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. . 1 .I <br /> APPLICANT'S SIGNATURE: J:(1r�31..A-m>L. DATE: o2l17=25 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER 2 OTHER AUTHORIZED AGENT COO <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 ByAs igned To Linked FA ID <br /> ici CA P, <br /> Date� �Q I PEE}„/R� Fee � <br /> cord Number <br /> IY/lV P�Sm��5� <br /> Rev 06/12/2024 <br /> �1<1 <br />