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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Departr `� <br /> Application Form <br /> Facility Name Deuel Vocational Institution <br /> Site Address 23500 Kasson Road City Tracy State CA ZIP 95304 <br /> AP�:2�39120�01 ���� <br /> Type of Service ❑Application for ❑Consultation 11Change of Owner ❑Repairs or Remodel IX Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> I$Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Casey Sanders Last name if contractor,Indicate type and license number <br /> Address2020 L Street, Suite 300 city State CA ZIP <br /> Sacramento 95811 <br /> Phone Phone Emall <br /> (916) 414-5800 �-asey.sanders@aecom.com AECOM <br /> ❑Billing Party ❑Facility Owner IN Facility Contac[ Cl Property Owner ❑Contractor 7❑Architect <br /> First Name Aaron Last name Coonfield If contractor,Indicate type and license number <br /> Address 23500 Kasson Road city Tracy State CA ZIP 95304 <br /> Phone Phone Ernail <br /> (209) 509-9079 <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Properly Owner C4 Contractor ❑Architect <br /> First Name Dennis Last name Ott If contractor,Indicate type and license number <br /> 0571012248 <br /> Address City State ZIP <br /> P.O. Box 6093 Oroville CA 95966 <br /> Phone Phone Email <br /> 530 693-0219 dennis@enprobe.us <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. / 10/16/2024 <br /> APPLICANT'S SIGNATURE: f— DATE: <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZEDAGENT Project Manager/AECOM <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 rile or my representative. <br /> Accepted By Assigned To Lin' 'r"rn <br /> Datef ` (2� PEq Fee �� c,v Record Nc'ftiPr <br /> ❑Cash 11 Check it ❑Conflrmation q Lid Payment <br /> Received By <br /> Rev 07/10/2024 <br />