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New Facility x❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> 1010 Industrial Dr <br /> Site Address city State ZIP <br /> 1010 Industrial Drive Stockton CA 95206 <br /> APN Supervisor District <br /> 177-280-530-000 1;Mario Gardea <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel M Other <br /> Requested Operating Permit <br /> Comments <br /> Application for 2 site mitigation well and boring permit applications(MW-04 and SV-07). <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types M 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 /> Molly Coates <br /> Address City State ZIP <br /> 1300 Clay St,Suite 1000 Oakland CA 94612 <br /> Phone Phone Email <br /> S10-645-1850 610-995-2248 molly.coates@teraphase. om <br /> El Billing Party ❑Facility Owner ❑Facility Contact El Property Owner Contractor ij! ❑Architect <br /> First Name Last n If contractor,indicate type and license number <br /> Ralph C-57;#1035255 <br /> Address City State ZIP <br /> 68218th Street m Rio Linda CA 1095673.y <br /> Phone Phone Email <br /> 707-639-7709 1 ;re(jahey@confluencete hnical.com <br /> Billing Party ❑Facility Owner ❑Facility Contact ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address Ci Sta ZIP <br /> 03 Wfi <br /> P1JQDe Phone E <br /> Or <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: --Y DATE: 2/3/2026 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER IM OTHER AUTHORIZED AGENT Sr Project Geologist,Terraphase Engineering <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 og my representative. <br /> Accepted By A Assigned To A,— Linked FA ID <br /> v la <br /> Date <br /> -Z t Z PE Fee Record Number c o 019 V a <br /> Payment <br /> ❑Cash ❑Check# *confirmation# Z! G� 1Z f Received By <br /> Rev 07/10/2024 <br />