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i <br /> ❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> White Slough Water Pollution Control Facility <br /> Site Address City State ZIP <br /> 12751 N.Thornton Road Lodi CA 95242 <br /> APN Supervisor District <br /> 05513016 District 4 <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel IO Other <br /> Requested Operating Permit <br /> Comments , <br /> Monitoring Well Destructions and Construction Hof r'�4 L4) 1 S lou7k LV AU V epr,(r�,�!`hn <br /> If mobile food truck or License Plate Number VIN <br /> pumpertruck N/A N/A <br /> Contact Types 0 Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> 0 Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Charles Hardy West Yost Associates <br /> Address City State ZIP <br /> 1001 Galaxy Way, Suite 310 Concord CA 94520 <br /> Phone Phone Email <br /> (925)949-5814 N/A chardy@westyost.cot <br /> ❑Billing Party 0 Facility Owner 0 Facility Contact —f 0 Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> City of Lodi N/A N/A <br /> Address City State ZIP <br /> 12751 N.Thornton Road Lodi CA 95242 <br /> Phone Phone Email <br /> (209)333-6749 (209)333-6832 kcapitanich@lodi.gov <br /> ❑Billing Party 77acility Owner ❑Facility Contact ❑Property Owner IO Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Ralph McGahey C-57 Contractor License#1035255 <br /> Address City State ZI P <br /> 6821 8th St. (Confluence Technical Services, Inc) Rio Linda CA 95673 <br /> Phone Phone Email <br /> (916)760-7641 N/A rmcgahey@conflUEncetechnical.com <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 appli do 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: 1 1/14/2025 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER El OTHER AUTHORIZED AGENT Enolneerino Consultant <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 To Linked FA ID <br /> � l <br /> Date I PE f ; Fee _3 Record Number <br /> `I 0 7 <br /> ❑Cash ❑Check H t l Payment <br /> f <br /> Received By <br /> Rev 07/10/2024 <br />