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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 /> 14000, 14098, &14320 N Alpin Road Lodi California 95240 <br /> M070 61 62 &63 Supervisor District <br /> 4 <br /> Type of Service ❑Application for Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other A l p� <br /> Requested Operating Permit IV T <br /> Comments B `® <br /> Surface Subsurface Contamination Report <br /> If mobile food truck or License Plate Number VIN <br /> pumpertruck r 201,95 <br /> IJA <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner , <br /> Contractor H NA?E N7y <br /> required T Deo NT L <br /> -NT <br /> ling Party acility Owner ❑Facility Contact perty Owner ontractor ❑Architect <br /> F' t Name Last name If contractor,indicate type and license number <br /> rsfoe Peterson <br /> Address City State ZIP <br /> 14000 N Alpine Road Lodi California 95240 <br /> P one Phone <br /> 20 9) 368-8010 (209) 210-8010[Em <br /> @agland.org <br /> PIgilling Party ❑Facility Owner ❑Facility Contact ❑Property Owner ntractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Joe Murphy <br /> Address City s tolfiiZIP <br /> PO Box 2180 Lodi a aorna 95241 <br /> P one Phone Email <br /> 209) 334-6613 jmurphy@dillor.andmurphy.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 applicati nand at the work to be permed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. � �r <br /> APPLICANT'S SIGNATURE: DATE: /1 L / —z <br /> ❑PROPERTY/BUSINSSS OWNER ❑OPERATOR/MANAGER �.pTHER 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 Record u ber <br /> _ay-z Zo3 Y C'��=� <br /> ❑Cash AC <br /> hedc p �� - ❑Confirmation q Payment <br /> Received By <br /> Rev 07/10/2024 <br /> 2521 <br />