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❑ New Facility ® Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Port of Stockton <br /> Site Address \' City State ZIP <br /> at,I/tc t vI,K c Stockton CA 95203 <br /> APN Supervisor Dist lCt <br /> 16203007 <br /> Type of Service ❑Application for sultation ❑Change of Owner ❑Repairs or Remodel er <br /> Requested 1 Operating Permit <br /> Comments 1N��/f' OV- ("J-J VL✓, ,r� c�%LA, <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner 0 Contractor ❑Architect <br /> required <br /> ❑Billing Party B Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name if contractor,indicate type and license number <br /> Port of Stockton <br /> Address City State ZI P <br /> 2201 Washington Street Stockton CA 95203 <br /> Phone Phone Email <br /> 209) 946-0246 <br /> Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner 0 Contractor ❑Architect <br /> Consultant <br /> First Name Last name If contractor,indicate type and license number <br /> Geosyntec Consultants Inc Environmental Consultant <br /> IP <br /> ddress City State ZI043 Gold Canal Drive, Suite#100 Rancho Cordova CA 95670 <br /> hone Phone Email <br /> 16-637-8048 1916-205-6833 �Martin@Geosyntec.corr <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 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: / // — DATE: 7/30/2025 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT Scientist,Geosyntec Consultants <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 Linked FA ID <br /> Date PE Fee Record Number <br /> 2410 5, �1- SR�581 q <br /> Payment <br /> ❑Cash ❑Check# Wconfirmation# ),0,' Received By <br /> Rev 07/10/2024 <br />