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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Elmer's Farm <br /> Site Address City State ZIP <br /> 10779 S.Airport Way Manteca CA 95336 <br /> APN Supervisor Di trict <br /> 177-500-28 3 I ? <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> Nitrate loading study/soil suitability report <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facillty Contact ❑Property Owner ntractor ❑Architect <br /> required <br /> ❑Billing Party ❑facility Owner ❑Facility Contact 7 <br /> ® Property ❑Contractor ❑Architect <br /> Owner <br /> First Name Elmer's Farm,LLC Last name If contractor,indicate type and license number <br /> Mari Robinson <br /> Address City State ZIP <br /> 8035 N.Pershing Avenue Stockton California 95209 <br /> Phone Phone Email <br /> mdn1687@icioud.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 /> P.O.Box 2180 Lodi California 95241 <br /> Phone Phone Email <br /> 209-334-6613 jmurphy@dillonandmurptiy.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 application and that the work to be perfor ed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. ss <br /> APPLICANT'S SIGNATURE: /�// �GC/ DATE: A-1�rr�� �+ <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER IN OTHER AUTHORIZED AGENT Representative <br /> .,.L,. <br /> Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required f�• ..� ' yy <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize 14 ()�� <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMkIl <br /> �Jl <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. In, <br /> `v <br /> Accepted By / Assigned Toni(_ _ V s Linked FA ID yILzivT <br /> Date PE Fee _ Record N m er 'r' <br /> Payment <br /> ❑Cash lvCheck p ❑Confirmation q Received By <br /> Rev 07/10/2024 <br />