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U 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 5A P- 210 Lodi CA 95240 <br /> APN Supervisor District <br /> Type of Service 0 Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck IN 3173846 13ALACWFC9NDMV560 <br /> Cantact Types 0 Billing Party ❑Facility Owner 0 FaciiityContact ❑Praperty Owner ❑Contractor �Q ArcliArchitect <br /> IR 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 [Support@kenston <br /> mail <br /> 256-404-1415 frms.com <br /> 11 Biiling Party ❑Facility Owner 0 Facility Cantact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Devin Byrd <br /> Address City State ZI P <br /> 5045 Whitmire Rd Milton FL 32570 <br /> Phone Phone Email <br /> 334-389-9387 <br /> ❑Billing Party ❑Facility Owner 0 Facility Contact ❑Property Owner r]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 killed 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: <br /> APPLICANT'S SIGNATURE: t,J i 1 L a\ _ DATE; 62/17/2025 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT COD • <br /> Title �!� <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required OI <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address, , orizeth`e <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVI MENT L <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. JOA <br /> H � N <br /> Accepted By Assigned To Linked FA ID Ity <br /> �EP,qf, NTAL rY <br /> Date <br /> aZ� 1� �Zr Z P ���� Fee �m cord Number <br /> 1 t z, �� o��� HP-25mi(06?_1 <br /> Rev 06/12/2024 C`L' <br />