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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address 444 Mossdale Road City State ZIP <br /> Lathrop CA 95330 <br /> APN Supervisor District <br /> 239-030-03 <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel Other <br /> Requested Operating Permit <br /> Comments Site Mitigation Well & Boring Permit Application <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck 1 7 <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact X Property Owner ❑Contractor ❑Architect <br /> SKSP Inc. <br /> First Name Last name If contractor,indicate type and license number <br /> Surendar Jiindal <br /> Address City State ZI P <br /> 1172 C Street Lodi CA 95240 <br /> Phone Phone Email <br /> 510-364-5771 cpa.skiindal0mmail.com <br /> lq Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner I4 Contractor ❑Architect <br /> Partner En neeriog & Science, Inc. —t <br /> First Name Last name If contractor,indicate type and license number <br /> Michel Helou <br /> Address City State ZI P <br /> 490 43rd Street Oakland CA 94609 <br /> Phone Phone Email <br /> 774-414-3666 mhelou@partneresi.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 ZI P <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 performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. ..- <br /> APPLICANT'S SIGNATURE: ` �`� DATE: 5/28/2026 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER (St OTHER AUTHORIZED AGENT Project Manager <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 Linked FA ID <br /> Date PE Fee `�.� Record Numbers R 2� 2.18 <br /> S f 1 •.18 0/VPayment <br /> ❑Cash ❑Check# .onfirmation q 221501218,221543122 Received By <br /> Rev 07/10/2024 <br />