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. <br /> O New Facility M Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application_ Form__ <br /> FadlityName PG&E Las Vinas Dehydrator Station <br /> Site Address 5300 W. Woodbridge Rd. city state ZIP <br /> 9 Lodi CA 95242 <br /> AP" 01116025 Supervisor District — <br /> Type of Service M Application for i ❑Consultation ❑Change of Owner ❑Repairs or Remodel I ❑Other <br /> Requested Operating Permit <br /> Comments <br /> Monitoring well decommissioning permits <br /> If moblle food truck or License Plate Number NA NA <br /> pumper"-ck <br /> Contact Types El Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> 12 Billing Party Facility Owner ❑Facility Contact ❑Property Owner i ❑Contractor ❑Architect <br /> First Name Ken Last name SImaS If contractor,indicate type and license number <br /> Address 300 Lakeside Drive cm' state nP -- <br /> Oakland CA 94612 <br /> Phone Phone Email Pacific Gas a ,d Electric <br /> 925-482-7606 KcSb@pge.com <br /> Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner 711 Contractor ❑Architect <br /> First Name Jonathan Last name Ferris If contractor,Indicate type and license number <br /> Address 2101 Webster Street, Suite 1410 uty Oakland State CA ZIP 94612 <br /> Phone —�--- Phone Email - --i-- _— � ----__.—_ <br /> 505-280-90881 Jonathan.Ferris 'acobs.com <br /> O Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner M Contractor ❑Architect <br /> First Name Gregg Drilling Last name if contractor,Indicate type and license number <br /> C-57: 1044456 <br /> Address Benicia state CA —�P 94510 <br /> 2100 Goodyear Rd <br /> Phone Phone Email <br /> 925-313-5800 _ <br /> BILUNG 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 tha0h 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: 4 <br /> �1 PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT Pro <br /> )eCt Manager-Env.Remedlatl0n PG&E <br /> Title <br /> If APPUCANT 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 IDv <br /> _1/ G� <br /> ,� PE Record Number fee S lY� w _ S 41501 ';Z -- <br /> 1 Payment <br /> ❑Cash ❑Check N Qkonfiirmation il Z O lk 2� `� Received By — <br /> aati m�tnnn�e <br />