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❑ New Facility El Existing Facility • San Joaquin County Environmental Health Department Application Form Facility Name Koppel Stockton Terminal Site Address she iW, ,ru Dvx- City Stockton State CA ZIP 95203 APN r*5-08tI"02 Supervisor District Type of Service ❑O Application for Wonsultation ❑Change of Owner ❑Repairs or Remodel ❑Other Requested Operating Permit Comments Application for workplan review �0'r'7► Wt j 9>q L-*- If mobile food truck or License Plate Number VIN pumper truck Contact Types ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect required 0 Billing Party ❑Facility Owner ❑Facility Contact 7 Property Owner ❑Contractor ❑Architect First Name Matt Last name Loughney If contractor,indicate type and license number Address 2705 Bee Caves Road,Suite 300 City Austin State TX ZIP 78746 Phone 304-613-9635 Phone Email matt.loughney@jacobs.com ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner OContractor ❑Architect First Name Gregg Drilling,LLC Last name If contractor,indicate type and license number Drilling Contractor/Lie#1044456 Address 2100 Goodyear Road City Benicia State CA ZIP 94510 Phone 925-313-5800 Phone Email info@greggdrilling.com ❑Billing Party ❑Facility Owner ❑Facility Contact O Property Owner ❑Contractor ❑Architect First Name Daniel Munzer/Munco,Inc. Last name If contractor,indicate type and license number Address 3450 E Spring St,Suite 218 City Long Beach State CA ZIP 90806 Phone 562-283-1014 Phone Email BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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, Standards,STATE and FEDERAL laws. APPLICANT'S SIGNATURE: I rV 1 / �' DATE: 5/15/2026 ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT Title If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address,hereby authorize the release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Accepted By 1 - Assigned To — Linked FA ID Date t PE 'L`t G Fee ,ak a Record Number 5�� O � /16 G / 220837190,220835567 Payment ❑Cash ❑Check# ❑Confirmation# 220834923 Received By Rev 07/10/2024