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❑ New Facility '� Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name Rough and Ready Island <br /> Site Address City State ZIP <br /> (f i" �1 1 -1�w Stockton CA 95203 <br /> APN 1�— upervisor District <br /> 16203007 District 1 <br /> Type of Service ❑Application for 1�;onsultation ❑Change of Owner ❑Repairs or Remodel Other <br /> Requested Operating Permit / <br /> Comments -7 , <br /> �k. `Cr,.V� t <br /> If mobile food truck or License Plate Number 7N/A <br /> N <br /> pumper truck N/A <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party IR Facility Owner ®Facility Contact M Property Owner ❑Contractor ❑Architect <br /> First Name Port of Stockton Last name If contractor,indicate type and license number <br /> Address 2201 Washington Street City Oakland State CA ZIP <br /> 95201 <br /> Phone 209 946 0246 Phone Email <br /> jcashman@stocktonport.com <br /> ®Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Geosyntec Consultants Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> 3043 Gold Canal Drive,Suite#100 Rancho Cordova CA 95670 <br /> Phone Phone Email <br /> 916-205-6833 <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner El Contractor ❑Architect <br /> First Name Penecore Drilling Last name If contractor,indicate type and license number <br /> 906899 <br /> Address 220 N.East Street City State ZIP <br /> Woodland CA 95776 <br /> Phone Phone Email <br /> 530-661-3600 <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. 2/20/202S <br /> APPLICANT'S SIGNATURE: DATE: <br /> ❑PROPERTY/BUSINESS OWNER ❑ RATOR/MANAGER MOTHER AUTHORIZED AGENT Billing Party <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 r1iy representative. <br /> Accepted By Assigned To C LinkedFAI> <br /> cat G <br /> Date PE Fee-��1� J V Record Numb-- <br /> "\ �(Lilk- <br /> Payment <br /> ❑Cash ❑Check# ❑Confirmlation# Received By <br /> Rev 07/10/2024 <br />