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S� �A G Vo 2— S )n I ❑ New Facility ® Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> North County Recycling Center & Sanitary Landfill <br /> Site Address City State ZIP <br /> 17720 E. Harney Lane Lodi CA 95240 <br /> APN Supervisor District <br /> 065-120-04 4 <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner ❑ Repairs or Remodel 0 Other <br /> Requested Operating Permit <br /> Comments <br /> Well Permit Application Solid Waste Investigation/Monitoring <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑ Billing Party ❑ Facility Owner 0 Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> required <br /> ❑ Billing Party ❑ Facility Owner 0 Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> Mark Houghton <br /> Address City State ZIP <br /> 1810 E. Hazelton Ave. Stockton CA 95205 <br /> Phone Phone Email <br /> (209) 468-3066 <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 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 ZIP <br /> Phone Phone —7 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: B�� DATE: 3/24/�)6 <br /> ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER E3 OTHER AUTHORIZED AGENT Senior Engineer <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 BACKUS Assigned To BACKUS Linked FA ID FA0004518 <br /> Date 3/25/26 PE 4407 Fee I ,, �. Recor Nu berD <br /> $179 5V724 (0 <br /> �0 <br /> ❑ Cash ❑ Check# / ❑ Payment <br /> Confirmation # Received By <br /> Rev 07/10/2024 PAID BY SST (aV <br />