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EMAILED <br /> ❑` `1 ZD\ �i n C�� New Facility El Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Glendenning Property <br /> Site Address City State ZIP <br /> 7001 E.Southland Rd. Manteca CA 95336 <br /> APN Superyisoi�ict <br /> 218-070-03 �'�/ <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel X Other <br /> Requested Operating Permit <br /> Comments <br /> Review Soil Suitability/Nitrate Loading Study <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 /> t$Billing Party ❑Facility Owner ❑Facility Contact N Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Gary Glendenning <br /> Address City State ZI P <br /> 7001 E.Southland Rd. Tracy CA 95336 <br /> Phone Phone Email <br /> (209)450-5112 gglenclenningl 3@gniail.com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner N 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@gma Isom <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Arcri{p� <br /> First Name Last name If contractor,indicate type and �, e <br /> Address City State ZIP//'/T <br /> Phone Phone Email y OAQU�4 <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site / t <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on AM, <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 lavAs. <br /> APPLICANT'S SIGNATURE: DATE: q" 1+- <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <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 Linked FA ID <br /> Date PE Fee �P�� Record Number - <br /> y�i z z;�� -oo �i 'lC-L 11�1-- <br /> Payment <br /> ❑Cash ❑Check# T-�f-irm-ti-n# o214�S� Received By <br /> Rev 07/10/2024 <br />