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❑ New Facility ® Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form _ <br /> Facility Name <br /> Park Woods Shopping Center <br /> Site Address City State ZIP <br /> (AAA 1782 West Hammer Lane Stockton California 95209 <br /> APN Supervisor District <br /> 07728031 02 <br /> Type of Service 0 Application for ®Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments Workplan review for 3 offsite soil borings for soil vapor and groundwater investigative borings for the Park Woods Cleaners site. <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types 0 Billing Party ❑Facility Owner ❑Facility Contact 0 Property Owner 0 Contractor ❑Architect <br /> required <br /> 0 Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Katherine Clark Environmental Consultant <br /> Address City State ZIP <br /> 3043 Gold Canal Drive Rancho Cordova California 95670 <br /> Phone Phone Email <br /> 916-287-2946 916-268-8169 Katherine.Clark@Geosyntec.co <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact 0 Property Owner ❑Contractor ❑Architect <br /> Sims-Grupe Management Corpo ation,Inc <br /> First Name Last name If contractor,indicate type and license number <br /> Phil Johnson <br /> Address City State ZI P <br /> 374 Lincoln Center Stockton California 95207 <br /> Phone Phone Email <br /> 209-478-9200 209-478-9200 piohnson@sims-grupe.com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner 0 Contractor ❑Architect <br /> Penecore Drilling <br /> First Name Last name If contractor,indicate type and license number <br /> Xavier Green C-59 Driller 91-icense No.06899 clo(OV19 <br /> Address City State ZIP <br /> 220 N East Street Woodland California 95670 <br /> Phone Phone Email <br /> 916-287-2946 Katherine.Clark@Geosyntec. <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. Z�� / <br /> APPLICANT'S SIGNATURE: KL ( - DATE: 12025 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT Engineer <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 By Assigned To Linked FA ID 0024399 <br /> Date PE Fee537.00 Record Number <br /> 12/3/2025 2903 S R.a <br /> ❑Cash ❑Check# ®Confirmation# Payment <br /> 212379267 Received By <br /> Rev 07/10/2024 <br />