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State <br />CA <br />ZIP <br />95304 <br />Site Address <br />16555 Von Sosten Road <br />City <br />Tracy <br />Facility Name <br />Lammersville Elementary School Kitchen <br />APN <br />20914009 <br />Type of Service <br />Requested <br />Supervisor District <br />5 <br />Application for <br />Operating Permit <br />Robert Rickman <br />0 Consultation 0 Change of Owner Repairs or Remodel 0 Other <br />Comments <br />Existing Kitchen Remodel <br />If mobile food truck or <br />pumper truck <br />License Plate Number <br />n/a <br />VIN <br />n/a <br />State <br />CA <br />City <br />Mountain House <br />Address <br />111 De Anza Blvd <br />0 Billing Party IN Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />Last name <br />Nicholas - Superintendent <br />If contractor, indicate type and license number First Name <br />Kirk <br />Phone <br />209-836-7400 <br />Email <br />knicholas@lamm ersvilleusd.net <br />Phone <br />ZIP <br />95304 <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 applica on nd th t the work to b erfor <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: <br />III be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />09/16/2024 DATE: <br />PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAG R • OTHER AUTHORIZED AGENT Architect <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 />111 New Facility II Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor ID Architect <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor Architect <br />First Name <br />Wesley <br />Last name <br />King <br />If contractor, indicate type and license number <br />Address <br />300 Knollcrest Drive <br />City <br />Redding <br />State <br />CA <br />ZIP <br />96002 <br />Phone <br />530-222-3300 <br />Phone Email <br />kinganmrdesign.com <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />Accepted By Vidal Pedraza Assigned To Kadeanne Linhares Linked FA ID <br /> <br />Date 9-16-24 PE 1601 Fee 516 Record Number <br /> <br />0 Cash 0 Check # 0 Confirmation # <br />Payment <br />Received By <br />Rev 07/10/2024 <br /> Payment 188304110