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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Ferriere/Mendoza Property <br /> Site Address City State ZIP <br /> 18895 & 18899 E. Sierra View Ct. Clements CA 95227 <br /> APN Supervisor District <br /> 019-260-58 <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel N 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 /> DO Billing Party ❑Facility Owner ❑Facility Contact 14 Property Owner ❑Contractor ❑Architect <br /> First Name Kim Ferriere Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> 1839 Oxford Way Stockton CA 95204 <br /> Phone Phone Email <br /> (209)405-5741 kimberlyferriere@gniail.com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner N 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 ZMMYCIVT <br /> 7 CEIVPr% <br /> First Name Last name If contractor,indicate type and license nJnfftAJ <br /> N <br /> Address City State SAN J zip <br /> Phone Phone Email HEALT 0EP ENTAL <br /> qR <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 wor to be performed will be done in accordance wit all SAN JOAQUIN COUNTY rclinance Codes, <br /> Standards,STATE and FEDERAL laws. _ _ 2 <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROP /BUSINESS OWNER ❑OPERATOR/MANAGER ❑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� /I YON Linked FA ID/`T"Q <br /> Daterr� (_ PE Fee y Record N mb j� <br /> 4 2 c 'it�Ada ljJ )1#1 <br /> Payment <br /> ❑Cash Check ri t if ❑Confirmation# <br /> � ! :) � ; Received By <br /> Rev 07/10/2024 <br />