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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Alpine&Sanford <br /> Site Address City State ZIP <br /> 848 North Alpine Road Stockton CA 95215 <br /> APN Supervisor District <br /> 103-020-120-000 <br /> Type of Service ❑Application for ❑ Consultation ❑ Change of Owner ❑ Repairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑ Billing Party ElFacility Owner ElFacility Contact ElProperty Owner ❑ Contractor El Architect <br /> required <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> Connor Schaumburg <br /> Address City State ZIP <br /> 1515 Des Peres Road,Suite 300 St. Louis MO 63131 <br /> Phone Phone Email <br /> 925-915-9070 c.schaumburg@trileaf.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 /> Tracy Pearse <br /> Address City State ZIP <br /> 848 North Alpine Road Stockton CA 95215 <br /> Phone Phone Email <br /> (209)481-7392 tpearse963@aol.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 /> Philip Cunningham <br /> C57 Contractor CA License#766463 <br /> Address City State ZIP <br /> 740 Williamson Ave. Fullerton CA 92832 <br /> Phone Phone Email <br /> 714-397-4942 philip@strongarmenv.conli <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. <br /> > i -- <br /> APPLICANT'S APPLICANT'S SIGNATURE: - DATE: 8/28/2024 <br /> ❑ PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Environmental Consultant-Trileaf Corporation <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 --s w( Assigned To �� Linked FA ID <br /> Date PE Fee S '��� Record Number <br /> �1 � a2 Zqo 3 = �t- -� g�zg�t S 0- - In o 4-3 <br /> I �30 �0I Payment <br /> ❑❑ Cash Check# *Confirmation# Received By <br /> Rev 07/10/2024P�� X ' S <br />