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)SkNew Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name Intermodal Way Parking Lot <br /> Site Address 2880 Intermodal Way City State ZIP <br /> Manteca CA 95336 <br /> APN Supervisor District <br /> 198-200-22 0 <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel Other <br /> Requested Operating Permit f <br /> Comments Application for environmental borings �'-X �r�V-'W�' <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Geosyntec Consultants,Inc. Contact:Stephanie Bone <br /> Address City State ZIP <br /> 8015th Avenue,Suite 2200 Seattle WA 98104 <br /> Phone Phone Email <br /> 480-540-5218 sbone@geosyntec.com <br /> ❑Billing Party XFacility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Sunrise Trucking Inc. <br /> Address City State ZIP <br /> 865 E Roth Road 95231 <br /> French Camp CA <br /> Phone Phone all <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact $Property Owner ❑Contractor ❑Architect <br /> First Name Sunrise Trucking Inc. Last name If contractor,indicate type and license number <br /> Contact:Mr.Sam Gill <br /> Address City State ZIP <br /> 865 E Roth Road <br /> French Camp CA 95231 <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 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: 't`'` (Geosyntec Consultants) DATE: 1/15/2026 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER Q OTHER AUTHORIZED AGENT Principal <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 T Linked FA ID <br /> — <br /> Date t+ PE fit,` y Fee „� Record Number <br /> tv SRaLb012 08 <br /> ayment <br /> ❑Cash ❑Check# r!(Confirmation# �S `� � Received By <br /> Rev 07/10/2024 <br />