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EMAILE <br /> ❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Wongphiboonrat Property <br /> Site Address City State ZIP <br /> 23304 S. Hansen Rd. Tracy CA 95304 <br /> APN Supervisor District <br /> 209-360-02 <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel KI 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 /> X Billing Party ❑Facility O%tner ❑Facility Contact 63J Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Gesaranee Wongphiboonrat <br /> Address City State ZIP <br /> same <br /> Phone Phone Email <br /> (510) 388-9249 gesaranee@live.corp <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property OwnerTLive <br /> ractor ❑Architect <br /> First Name Last name actor,indicate type and license number <br /> Abby Racco ak GeoEnvironmental, CEG 2151 <br /> Address City ZIP <br /> 407 W. Oak St. Lodi CA 95240 <br /> Phone Phone Email <br /> (209) 369-0375 liveoak.enviro@gmall.com <br /> ❑Billing Party ❑facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type �ir(¢4 dtolf��ymber <br /> Address City State �At� <br /> Phone Phone Email ^,. <br /> n, <br /> BILLING ACKNOWLEDGEMENT:I,the undersign4e ,iness owner,operator or authorized agent of same,ackn"Iedgp ttiat'av sib aA Dr Project <br /> specific ENVIRONMENTAL HEALTH DEPART NITssociated with this project or activity will be billed to me or my'business asideniif)edon`iks <br /> form. <br /> I also certify that I have prepared this applicat r o be performed will be done in accordance with I SAN 1 Q IN CO NTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPUCANT'S SIGNATURE: DATE: <br /> ❑PROPERTY/BUSINESS OWNER ❑ AGER ❑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 Linked FA ID <br /> tPE <br /> Date FeeAr <br /> Recor N� � . 7l� ,ct) � �-/, Payment Y/j❑Cash eck N �Conflrmation fi 'Z.G U Received B L/1 <br /> Rev 07/10/2024 ����/� ✓ N � i`t �l �' �i`lew�: <br />