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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Boyett Petroleum #113 <br /> Site Address City State ZIP <br /> 420 W Kettleman Lane Lodi CA 95240 <br /> APN Supervisor District <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner ry1 Repairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> Comments <br /> �/�--Zo$ anZ VR- 3K3 s¢nsors <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> I F <br /> Contact Types ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> required <br /> Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> CGRS, Inc Matt Thomas A/HAZ 803616 <br /> Address City State ZIP <br /> 5444 Dry Creek Road Sacramento CA 95838 <br /> Pho <br /> ne Phone Email l626-627-8316 916-991-1100 mthomas@cgrs.com <br /> 12 Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> same <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architeri< <br /> First Name Last name If contractor, indicate type and licery�e <br /> Address City State ZIP JqN <br /> Phone Phone EmailFw <br /> A <br /> NJCq QU <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and AL <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 416Aq. <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. <br /> APPLICANT'S SIGNATURE: �//1.90� DATE: 1-16-2025 <br /> ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/MANAGER 12 OTHER AUTHORIZED AGENT Compliance Services Manager-CGRS <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 k — Assign Linked FA ID <br /> Nuix b (L f A ©D -2 7 762 <br /> Date i I PEe6O 8 Fee �{tjj Record Number <br /> t Vj R mS� m S <br /> ❑ Cash ❑ Check# +onfirmation # S�7 Payment <br /> Received B <br /> Rev 07/10/2024 <br />