Laserfiche WebLink
EMAI LE D ❑ New Facility ❑ Existing Facility <br /> San 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 Supervis District <br /> 055-070-01 a� 7' <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel 11 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 ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑contractor ❑Architect <br /> j required <br /> N Billing Party ❑Facility Owner ❑Facility Contact j10 Property Owner ❑Contractor ❑Architect <br /> First Name Diego Olagaray Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> 2375 W.Armstrong Rd. Lodi CA 95242 <br /> Phone Phone Email <br /> (209)649-8841 1 1 diegoolagaray@yatioo.com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner 19 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@gmaii.com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> L- <br /> First Name Last name If contractor,indicate type and licen <br /> Address City State ZIP <br /> Phone Phone Email aAfIv <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge tKN4q, M (47 <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as i a06 <br /> form. A� <br /> I also certify that I have prepared this applicati nd that the w to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Code <br /> Standards,STATE and FEDERAL laws. !! i <br /> APPLICANT'S SIGNATURE: DATE: <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER MOTHER AUTHORIZED AGENT OtysleIrTIK^.-f <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 - i Linked FA ID <br /> Date PE Fee Record Number <br /> ~ 1 Payment❑Cash ❑Check it Confirmation K c2` — 7 r 7S� Received By 1 <br /> Rev07/10/2024 k(,4 SLA6 h t - <br />