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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form __ <br /> Facility Name <br /> Site Address City State ZIP <br /> 3359 N. Fine Road Linden CA 95236 <br /> APN Supervisor District <br /> 105-240-04 q? <br /> Type of Service ❑Application f r ❑Consultation ❑Change of Owner ❑Repairs or Remodel Other <br /> Requested Operating Permit <br /> Comments <br /> Nitrate Loadina Studv and Soil Suitability Re ort <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 /> required <br /> IN Billing Party ❑Facility Owner ❑Facility Contact ®Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Beckley Legacy LLC C/O Heather Carr <br /> Address City State ZIP <br /> 3359 N.Fine Road/PO Box 184 Linden CA 95236 <br /> Phone Phone Email <br /> 209-993-7316 1 1 fm5star@outlook.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 /> Joe Murphy <br /> Address City State ZIP <br /> PO Box 2180 Lodi CA 95241 <br /> Phone Phone Email <br /> 209-334-6613 jmurphy@dillonaniimurphy.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 <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 app' wn and t at the work to be performed will be done in accordance witp 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 Engineer <br /> Title �f9 <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 aut <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH e I <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Aon �O <br /> Accepted By Assigned To N Linked FA ID ✓ q <br /> h� <br /> Date PE Fee Record N b T �N Co <br /> Y*',� #-/n, OAV 11014-ZZ,- 4- <br /> ❑Cash heck# ILI, ❑Confirmation# Payment <br /> W Received B47. <br /> Rev 07/10/2024 <br />