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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> 230 Industrial Ave. - Ripon Nestle Site <br /> Site Address City State ZIP <br /> 230 Industrial Ave Ripon CA 95366 <br /> APN Supervisor District <br /> Type of Service ❑Application for !V-Consultation ❑Change of Owner ❑Repairs or Remodel 0 Other <br /> Requested Operating Permit <br /> Comments <br /> Workplan Review <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types 0 Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner 0 Contractor ❑Architect <br /> required <br /> 0 Billing Party ❑Facility Owner ❑Facility ContactTi�perty Owner ❑Contractor ❑Architect <br /> Haley&Aldrich, In . <br /> First Name Last name If contractor,indicate type and license number <br /> Cameron Paez <br /> Address City State ZIP <br /> 426 17th St Suite 700 Oakland CA 94612 <br /> Phone Phone Email <br /> 949-554-4566 cpaez@haleyaldrich.co <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner 0 Contractor ❑Architect <br /> Geocentric Drilling, Inc. <br /> First Name Last name If contractor,indicate type and license number <br /> Mike Cramer C-57 Driller-1073146 <br /> Address City State ZIP 95691 <br /> 1980 S River Rd Suite E West Sacramento CA <br /> Phone Phone Email <br /> 916-304-2665 mike@geocentricdrilling com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact 7 0 Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> City of Ripon <br /> Address City State ZI P <br /> 259 N Wilma Ave Ripon CA •-96662--Q53C0 <br /> Phone Phone Email <br /> 209-599-2108 <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 thi tion and t t work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL s. <br /> APPLICANT'S SIGNATURE: DATE: 419r16 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR QANAGER 0 OTHER AUTHORIZED AGENT Haley&Aldrich <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 By Assigned To Linked FA ID <br /> i t7(7"L 7`k t ) <br /> Dat�e PE 7' 6 ,� Fee Record Number <br /> Payment <br /> ❑Cash v ❑Check# 0 Confirmation# p <br /> •tC 2 t�7i ��Z��� Received By <br /> Rev 07/10/2024 <br />