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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Larry's Auto <br /> Site Address City State ZIP <br /> 308 N. Grant Street Stockton CA <br /> APN Supervisor District 9 <br /> 139-320-130 <br /> Type of Service ❑Application—forOth <br /> B Consultation ❑Change of Owner ❑Repairs or Remodel ❑ er <br /> Requested Operating Permit Environmental <br /> Comments <br /> Application form in support of a site mitigation well and boring permit to destroy multiple wells <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party J'ffiFEa cility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> e Billing Party ❑Facility Owner ❑Facility Contact la Property Owner ❑Contractor ❑Architect <br /> First Name last name If contractor,indicate type and license number <br /> Donna Skobrak <br /> Address City State ZIP <br /> 706 N. El Dorado Street Stockton CA 95202 <br /> Phone Phone Email <br /> (209)465-2667 sskobby@aol.com <br /> ❑Billing Party ❑Facility Owner Cl Facility Contact ❑Property Owner ®Contractor ❑Architect <br /> First Name Last name If contractor,Indicate type and license number <br /> John Lane PG#6795 <br /> Address City State ZIP <br /> 188 Frank West Circle, Suite I Stockton CA 95206 <br /> Phone Phone Email <br /> (209)234-0518 jlane@condorearth. om <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address <br /> City State ZIP <br /> Phone Phone Email <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or bL siness 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 activitywill 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 OUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws tt'' nn {y� <br /> IAPPLICANT'SSIGNATURE: �A''a nzli f59,4-IJ`'1/ZY,k DATE: <br /> +0 PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> I If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required Title <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 /> n <br /> fc—cepted—BT/y ,/ ;Assigned To/ / Linked FA ID 3b b <br /> ate 7 PE z'1 Record N ber) l <br /> Cash ❑Check# t Confirmation# l G W �1J Payment <br /> Received By <br /> R v 07/10/2024 <br />