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❑ New Facility X Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name STOCKTON UNIFIED SCHOOL DISTRICT - WEBER INSTITUTE Site Address City State ZIP 302 WEST WEBER AVENUE STOCKTON CA 95203 APN Supervisor District Address City State ZIP 137-270-220-000 STOCKTON CA 95205 Phone Phone Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner ❑ Repairs or Remodel B Other Requested Operating Permit WFNT 800-511-9300 Comments UST REMOVAL If mobile food truck or License Plate Number VIN pumper truck Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect required If contractor, indicate type and license number VICKIE BRUM Payment Received By Address City Billing Party ❑ Billing Party El Facility Owner ❑Facility Contact ❑Property Owner L1 Contractor Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect First Name Last name If contractor, indicate type and license number VICKIE BRUM Payment Received By Address City State ZIP 1944 EL PINAL DRIVE STOCKTON CA 95205 Phone Phone Email STOCKTON CA 95215 (209) 933-7045, ext. 2341 Phone vbrum@stocktonusd.nel WFNT ❑ Billing Party ❑Facility Owner ❑Facility Contact 11 Property Owner Contractor L1 Architect \v GA1 l' Date x,�z ❑Architect First Name Last name If contractor, indicate type and license number JOSE HERNANDEZ Payment Received By Address City State ZIP 1944 EL PINAL DRIVE STOCKTON CA 95205 Phone Phone Email STOCKTON CA 95215 (209) 933-7045, ext. 2353 Phone Email WFNT BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledg tl II a n,�?R \v GA1 l' Date x,�z PE Record Number � a50(2) 93a ❑ Cash d4heck # 036 ❑ Confirmation # Payment Received By First Name Last name If contractor, indicate type and license number ROBERT MARTY A-HAZ, C-57 1063765 Address City State ZIP 837 SHAW ROAD STOCKTON CA 95215 Phone Phone Email WFNT 800-511-9300 rmarty@advancedgeo.biz RECEIVED oject specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identi ie on this form. SAN JOAQUIN COUNTY ENVIR�M1tE��Tnn� I also certify that I have prepared this alpdo d e work be performed will be done in accordance with all SAN JOAQUIMEGUNrJd}tkMl nonce Codes, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: r/ 'Fu' n' DATE: 01-22-2025 ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MA;/AGER ® OTHER AUTHORIZED AGENT President/AGI -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 C ` �� Assigned To H a � et � {T e ,J Linked FA ID F 4 C� \v GA1 l' Date x,�z PE Fee �I Record Number � a50(2) 93a ❑ Cash d4heck # 036 ❑ Confirmation # Payment Received By Rev 07/10/2024