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* <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name Walmart - LODI #1789-279 <br />City LODI State CA ZIP 95241 <br />Supervisor District <br /> Consultation Change of Owner X Repairs or Remodel Other <br />License Plate Number VIN <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor X Architect <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor X Architect <br />Last name Moun If contractor, indicate type and license number <br />Address 6351 Citadel Drive State CA ZIP 92647 <br />Phone 949-466-8978 Phone <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />First Name If contractor, indicate type and license numberLast name <br />Address City State ZIP <br />Phone Phone Email <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />Address City State ZIP <br />Phone Phone Email <br />.5/9/24.DATE: <br /> PROPERTY / BUSINESS OWNER OPERATOR / MANAGER <br />Assigned ToAccepted By <br />1 -it <br />PE Fee -o-oDate <br />| A <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 />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br /> Application for <br />Operating Permit <br />Email <br />fenn.moun@wdpartners.com <br />x OTHER AUTHORIZED AGENT - SR permit manager <br />Title <br />City Huntington <br />Beach <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 the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. JfLVvV MC'ILA' <br />APPLICANT'S SIGNATURE: <br />Linked FA ID . Q £ ~2. $ <br />Record Number <br />apn 058-030- <br />12________ <br />Type of Service <br />Requested <br />Comments Request health plan review for Walmart remodel <br />First Name Fenn <br />Site Address 1601 S Lower Sacramento Blvd LODI CA 95241