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❑ New Facility ❑ Existing Facility <br /> E ,, AILLD <br /> ., San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Lopez Property <br /> Site Address City State ZIP <br /> 9198 W. Lorraine Rd. Tracy CA 95377 <br /> APN Superviso District <br /> 248-060-22 C�tj <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel DO Other <br /> Requested Operating Permit <br /> Comments <br /> Review Soil Suitability/Nitrate Loading Study <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner T <br /> Contractor ❑Architect <br /> required <br /> t$Billing Party ❑Facility Owner ❑Facility Contact 14 Property Owner ❑Contractor ❑Architect <br /> First Name Iherson Lopez Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> /9 Ir v LO�'lai Re?4 fiir.G G� 9�3 <br /> Phone Email <br /> Phone <br /> 831-905-4273 ihersonortigoza5@g ail.com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner N Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Abby Racco Live Oak GeoEnviron mental, CEG 2151 <br /> Address City State ZIP <br /> 407 W. Oak St. Lodi CA 95240 <br /> Phone Phone Email <br /> (209)369-0375 liveoak.enviro@gma Isom <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and <br /> Address City State zip <br /> l <br /> Phone Phone Email MAR <br /> r <br /> S � 20 <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledg (f/N <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my busin ' AVAL <br /> form. /? �y' <br /> I also certify that I have prepared this application and t a k to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance C deb <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: pa/9q/9R <br /> KPROPERTY/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 ByH Assigned To Linked FA ID <br /> a� <br /> Date PE Fee Re r u <br /> 3 3o�i( Z z *7/ •oa _ <br /> ❑Cash ❑Check# Confirmation# Payment <br /> /1/ /� a1 z Jo 13� Received e <br /> y 4 Rev 07/10/2024 Q a� at1W�` / 671 I <br />