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EMAI LED 0 New Facility 0 Existing Facility <br /> la- - 5@R Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Olagaray Property <br /> Site Address city State ZIP <br /> 11510 W. St. Rt. 12 Lodi CA 95242 <br /> APN Supery District <br /> 055-070-01 ��j/!/!//?17 <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel 19 Other <br /> Requested Operating Permit <br /> Comments <br /> Review Surface&Subsurface Contamination Report <br /> if mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types El Billing Party ❑Facility Owner �❑Facility Contact l ❑Property Owner ❑Contractor ❑Architect <br /> i <br /> i required <br /> 00 Billing Party 0 Facility Owner ❑Facility Contact 4 Property Owner ❑Contractor ❑Architect <br /> I <br /> First Name Diego Olagaray Last name If contractor,indicate type and license number <br /> Address 2375 W.Armstrong Rd. City Lodi State CA ZIP 95242 <br /> Phone Phone Email <br /> (209)649-8841 1 1 diegoolagaray@yatioo.com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact -T❑Property Owner Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Abby Racco Live Oak GeoEnvironmental, CEG 2151 <br /> Address City State ZIP <br /> 407 W. Oak St. Lodi CA 95240 <br /> Phone Phone Email <br /> (209) 369-0375 liveoak.enviro@gma I.com <br /> ❑Billing Party ❑Facility Owner LLa,'taname <br /> y Contact ❑Property Owner ❑Contractor ❑Ar�jt ct <br /> Aap-.J <br /> First Name If contractor,indicate type an �+�i�,p m <br /> Address City State ZlglreC <br /> 02 <br /> UD -' <br /> Phone Phone Email r/OAQU <br /> /N <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all si e <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on �� <br /> form. <br /> I also certify that I have prepared this applicati nd that the 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: DATE: <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER (OTHER AUTHORIZED AGENT C O/Vf'+/l nNf er _ <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 /V Assigned To ( Linked FA ID��a h <br /> Date PE Fee Record Number <br /> zy o 3 � d <br /> ❑Cash ❑Check u I Confirmation q n I "1 I i Payment <br /> o� ( S Received By ( � <br /> `Rev 07/10/2024 <br /> mwGlu r.3�,� S74�� ,- -ao�,c.,, - (..uploaded into Accela <br />