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❑ New Facility ❑ Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name Lodi-125 N Stockton Site Address City State CA ZIP 125 N Stockton St Lodi 94610 APN Supervisor District 043-084-130 Type of Service ❑Application for ❑ Consultation ❑ Change of Owner ❑ Repairs or Remodel ❑ Other Requested Operating Permit Site investigation sc it boring Comments r� If mobile food truck or License Plate Number PIN pumper truck Contact Types ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑Architect required Il Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect First Name Last name If contractor, indicate type and license number Cynthia Breene Environmental Consultant Address Cit State ZIP 1999 Harrison St, STE 500 Oland CA 94610 Phone Phone Email 510-302-6341 cynthia.breene@tetratech.com ❑ Billing Party ❑ Facility Owner ❑ Facility Conta!77 Property Owner ❑ Contractor ❑ Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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, Standards,STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 6/12/2E ❑ PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER 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 Asl d T' Linked FA ID Dat PE Fee I J Record Number � l � _S `IDS ❑ Cash [ICheck# ❑ Confirmation# PaymentReceived By Rev 07/10/2024