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❑ New Facility �� Existing Facility <br /> Can Innm tin rrs,inty PmArnnmcntal 4- anith Nnnnrtmnnt <br /> J I.I I 1 I VLAM MI I 1 �.rV M I.%y — I•I 11 V.0.11— I%—. 1 I�r\A 1 LI I V—r— U111�. 1. <br /> 1 A r�r��i��tinr� Cnrm <br /> Facility Name <br /> T ayior Automotive <br /> Site Address City State ZIP <br /> JJJG Last 1 IGIIIVIIL JU GGI VlV Vn1V 11 vn .7LJ IL <br /> APN Supervisor District <br /> 43-360-040-nnn <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit I <br /> I Comments �c cz%JI-- vim` � l �.(, ll1AF�I�G,�•Vt� b- P."'�,F -:_._ <br /> If mobile food truck or I License Plate Number I VIN <br /> pumper truck <br /> Contact Types 0 Billing Party ❑Facility Owner ❑Facility Contact 0 Property Owner ❑Contractor ❑Architect <br /> required <br /> 0 Billing Party ❑Facility Owner ❑Facility Contact 0 Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address city State ZIP <br /> P.O. Box 1447 Lodi CA 95241 <br /> 1Phone Phone Email <br /> 707-486-8894 fasteasy 101 @gmail.com <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 City State ZIP <br /> Phone Phone Email � 1 <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner 0 Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Advanced Geo Inc. _ A-HAZ, C-57 License#1063765 <br /> Address City State ZIP <br /> 837 Shaw Road sockton cn 95215 <br /> Phone Phone Email <br /> 800-511-9300 I murah@advancedgeobtz <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 th work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> S!--nd,rds STATE 2nd rrCronl l2. <br /> APPUCANT'S SIGNATURE: DATE: >Z! <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Title <br /> If!1PP !CANT--ct ti.e ali U ICi onury •^Sign or 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,geolechnical 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 /> Accented By �l Assiened To 1 Linked FA ID <br /> Date I PE Fee \ Record N tuber <br /> n rat `I 17 Check N narr•tation# 2 Payment <br /> Kecelved tJy <br />