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r'^ [K] New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> OLSON TRUST PROPERTY <br /> Site Address City State ZI P <br /> 125 East Lodi Avenue Lodi CA 95240-2906 <br /> APN Supervisor District <br /> 043-063-080-000 <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types N 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 /> Benjamin r9ATR� Khatirine <br /> Address City State ZIP <br /> 14749 North Thornton Road Lodi CA 95242 <br /> Phone Phone Email <br /> (916) 261-6194 Ila hatirine@gmaii.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 ZIP <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 rk to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE.and FEDERAL laws. <br /> 024 <br /> APPLICANT'S SIIGNATURE: DATE: 08�27� — <br /> ❑PROPERTY/BUSINESS OWNER ElOPERATOR/MANAGER 16 <br /> OTHER AUTHORIZED AGENT lnr4l V � <br /> ' Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required p*.Q., � / ��l le � �,ti, <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above site address, Fereby authorize the <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH,�Z� e lL <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> Accepted By Assigned To Linked FA ID �NJ <br /> Date PE Fee Record Number:^ 12 Ito L 1 '5 1 <br /> gg 50 <br /> Xconfirmation <br /> Payment <br /> 1-1Cash ❑Check# # J Received By �lJ <br /> 1. <br /> Rev 07/10/2024 <br />