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• ❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name Deuel Vocational Institution <br /> Site Address 23500 Kasson Road City Tracy State CA ZIP 95304 <br /> APN 23912001 Supervisor District <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel IN Other <br /> Requested Operating Permit 11 <br /> Comments 1�'L Irk IiF <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 /> CK Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Casey Last name Sanders If contractor,indicate type and license number <br /> Address 2020 L Street, Suite 300 city State Sacramento CA Z1P 95811 <br /> Phone Phone Email <br /> (916) 414-5800 1 casey.sanders@aecom.com AECOM .N <br /> ❑Billing Party ❑Facility Owner CK Facility Contact ❑Property Owner ❑Contractor ❑Architect U <br /> f <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 Email <br /> (209) 509-9079 74 <br /> ter <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner 04 Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Dennis Ott C57 1012248 . <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. j <br /> APPLICANT'S SIGNATURE: /47 — DATE: 0/16/2024 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ll OTHER AUTHORIZED AGENT 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 me or my representative. <br /> Accepted By Assigned To s Lir', <br /> Date PE Fee Record NC"`�a• <br /> ,c <br /> ❑Cash ❑Check# ,o�Confirmation ri c,(— Payment <br /> Received By <br /> Rev 07/10/2024 c �(�pi <br />