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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Lodi-125 N Stockton <br /> Site Address City State ZIP <br /> 125 N Stockton St Lodi CA -948 45240 <br /> APN Supervisor District <br /> 043-084-130 <br /> Type of Service ❑Application for Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit('_, ` Site investigation sc it boring <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 0 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 /> Cynthia Breene Environmental Consultant <br /> Address C ity State ZIP <br /> 1999 Harrison St, STE 500 Oakland CA 94610 <br /> Phone Phone Email <br /> 510-302-6341 cynthia.breene@tetratech.com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZI P <br /> Phone Phone Email <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. <br /> APPLICANT'S SIGNATURE: � '�Q' DATE: 6n2i25 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <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 Assi d T Linked FA ID <br /> _ 6 D214 kk <br /> Dat II PE Fee Record Numb <br /> ❑Cash ElCheck# Confirmation# Z pZ 4?DD Payment <br /> O Received By <br /> Rev07/10/2024 <br />