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s <br /> ❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name OXYCHEM STOCKTON <br /> Site Address 1904 West Charter Waycity state zIP <br /> Stockton California 95206 <br /> APN 163-020-41 supervisor District <br /> Type of Service ❑Application for Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments (� S�� �� �✓i j \ ' I <br /> Consultation for review of boring permit application and related documents <br /> If mobile food truck or License Plate Number VI N <br /> pumper truck <br /> Contact Types Billing Party ❑Facility Owner ❑Facility Contact 50 Property Owner ❑Contractor ❑Architect <br /> required <br /> 09 Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Ron Gestler <br /> Address City State ZI P <br /> 1340 Treat Boulevard,Suite 208 Walnut Creek CA 94597 <br /> Phone Phone Email <br /> 925 278 8688 rgestler@geosyntec.com Geosyntec Consultants,In . <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact 00 Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Lisa Waskom <br /> Address City State ZI P <br /> 5 Greenway Plaza,Suite 110 Houston TX 77046 <br /> Phone Phone Email <br /> 713 552 8765 lisa_waskom@oxy.com Glenn Springs HoldinT1c. <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 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 ass ciated 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 applica' an th e w to a performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: August 11,2025 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER OTHER AUTHORIZED AGENT Project Director <br /> Itle <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 U Ltd <br /> �u \ <br /> Date 11 PE Fee ? R cord Number <br /> b�R.2`D(l) V BCD <br /> �{ v Payment <br /> ❑Cash ❑Check# C4bnfirmation# Z G �� p z-t Received By <br /> Rev 07/10/2024 <br />