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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Former Toyota Town <br /> Site Address City State ZIP <br /> 610 North Hunter Street Stockton CA 95202 <br /> APN Supervisor District <br /> 139-060-330-OOC 1 <br /> Type of Service ❑Application for X Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments Workplan review for well destruction <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types IN Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact B1 Property Owner ❑Contractor ❑Architect <br /> First Name Last na mp If contractor,indicate type and license number <br /> Service First of Northern Californiac/o Vernel Hill <br /> Address City State ZIP <br /> 102 W. Bianchi Rd. Stockton CA 95207 <br /> Phone Phone Email <br /> 209 644-6300 1vhi ll@servicefirs nc.org <br /> R Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> ATC Group Services, LLC dba A las Technical <br /> Address City State ZIP <br /> 1117 Lone Palm Avenue, Suite 201 B Modesto CA 95351 <br /> Phone Phone Email <br /> 209-579-2221 'eanne.homse oneatlas.com <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 /> Confluence Technical Services I c. C-57 1035255 <br /> Address City State ZI P <br /> 6821 8th Street Rio Linda CA 95673 <br /> Phone Phone Email <br /> 707 639-7709 rmc ahe con luencetechnical. om <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 a lication and_WaJ the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. qyw, <br /> APPLICANT'S SIGNATURE: DATE: 08/1 1/2025 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER OTHER AUTHORIZED AGENTConsultant, Branch Mqr. <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 B Assigned Linked FA ID <br /> Dat PE Fee Record Number <br /> $ 2 3 �3 SR2.5m13Co5 <br /> ❑Cash ❑Check# Confirmation# Payment <br /> 2���� V Received By <br /> Rev 07/10/2024 <br />