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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Anderson Property <br /> Site Address City State ZIP <br /> 20295 &20795 S. Van Allen Rd. Escalon CA 95320 <br /> APN Supervisor istrict <br /> 245-120-14 s/99 <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel EI 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 /> N Billing Party ❑Facility Owner ❑Facility Contact M Property Owner ❑Contractor ❑Architect <br /> First Name Christine Anderson Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> 20295 S.Van Allen Rd. Escalon CA 95320 <br /> Phone Phone Email <br /> (209)481-5337 chanderson@sjcoe.r et <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact 7 <br /> ❑Property Owner ®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 l.com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor t <br /> e <br /> First Name Last name If contractor,indicate ty er <br /> Address City State Sq 2026 <br /> Phone Phone Email EN W //y c® <br /> H�CT NEE UNn' <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site a rroject <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 al7SAN AQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL lawAPPLICANT'S SIGNATURE: i[_,L��1 � DATE: / 2 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER 2 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 / n _ Linked FA ID <br /> Date 27 PE A J_ O/> _ Fee �� Record Number <br /> Payment <br /> ❑Cash ❑Check# kcol--f-rmltion# pL,rly� t Received By <br /> Rev 07/10/2024 <br />