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•*tom �r�+Twsxl"a31T7'T T11«� �TTj�+I I IA A�� 11S�RF�C[31�"M 7r t 1 r:4r, <br /> ❑ New Facility © Existing Facility <br /> San Joaquin County Environmental Health Department <br /> _ Application form____ <br /> Facility Name <br /> Lakewood Plaza <br /> Site Address City State ZIP <br /> 306&308 North Ham Lane Lodi CA 95242 <br /> APN Supervisor District <br /> 037-100-300 <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑ Repairs or Remodel IN Other <br /> Requested Operating Permit <br /> Comments b6 -- - ermit 1 — <br /> ( � 7 5 � v l—z- VI/L ti C) ✓i L <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 /> Cl Billing Party ❑Facility Owner 1l Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Michael Gurev <br /> Address City State ZIP <br /> 1818 Grand Canal Boulevard,Suite 4 Stockton CA 95207 <br /> Phone Phone Email <br /> 916-527-8234 lmgurev@freemanfirm.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 /> Daniel Villanueva C57: 1063765 <br /> Address City State ZIP <br /> 837 Shaw Road Stockton CA 95215 <br /> Phone Phone Email <br /> 800-511-9300 dvillanueva@advancedge o.biz <br /> m Billing Party ❑Facility Owner ❑Facility Contact M Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> John Godi <br /> Address City State ZIP <br /> 4285 Spyres Way Modesto CA 933 <br /> Phone Phone Email <br /> 209-577-1280 johngodi@sundancecre corn <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. 06/23/2025 <br /> APPLICANT'S SIGNATURE: DATE: <br /> ®PROPERTY/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 Linked FA ID <br /> Date ���j PE � J � Fee � L/ 4�' Records R a 5 0 a;Z 4 <br /> (�� <br /> ❑Cash ❑Check# Conflrmatlon# �U� l "�"� Payment <br /> Received By <br /> Rev 07/10/2024 <br />