Laserfiche WebLink
® New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> 601 North Central Avenue <br /> Site Address 601 North Central Avenue City State ZIP <br /> Tracy CA 95376 <br /> APN 235-069-09,-10,-11,-12, Supervisor District <br /> -13.-15,and-16 <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ®Other <br /> Requested Operating Permit <br /> Comments EHD Site Mitigation Program workplan review <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner r <br /> Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ®Property Owner ❑Contractor ❑Architect <br /> First Name CRP Affordable Housing and Last name If contractor,indicate type and license number <br /> Community Development <br /> Address 4455 Morena Boulevard, Suite 107 City State ZIP <br /> San Diego CA 92117 <br /> Phone Phone Email <br /> 909-206-9177 <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner I@ Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Environmental Control Associates, Inc. C-57:695970 <br /> Address 3011 Twin Palm Drive city state ZIP <br /> Aptos CA 95003 <br /> Phone Phone Email <br /> 831-662-8178 <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 /> Partner Engineering and Science, Inc. <br /> Address City State ZIP <br /> 1512 Eureka Road, Suite 205 Roseville CA 95661 <br /> Phone Phone Email <br /> 916-405-1275 <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. <br /> APPLICANT'S SIGNATURE: --f5 DATE: 9/26/2025 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER MOTHER AUTHORIZED AGENT Agent for Owner <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 Linked FA ID <br /> Date PE� Fee w Record Number3 3 SRa50I5 <br /> ❑Cash ❑Check# r Payment <br /> Ly�Confirmation# C 'L ``� 3 ' Received By <br /> Rev 07/10/2024 <br />