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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Site Address City State ZIP <br /> 4910 and 4915 E.Clarksdale Road Acampo CA 95220 <br /> APN Supervisor District <br /> 017-090-56 and 59 q <br /> Type of Service ❑Appl ation for ❑Consultation ❑Change of Owner ❑Repairs or Remodel gOther <br /> Requested Operating Permit <br /> Comments <br /> Surface Subsurface Contamination Report <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑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 /> Chelsea Chandler <br /> Address City State ZIP <br /> P.O.Box 9041 Stockton California 95208 <br /> Phone Phone Email <br /> 209-981-7346 1 1 chelsealynnchandl r@yahoo.com and chelseachand icloud com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner Is&]Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Joe Murphy <br /> Address City State ZI P <br /> P.O.Box 2180 Lodi California 95241 <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑contractor ❑Architect <br /> First Name Last name If contractor,indicate type c�jyQy ber <br /> Mr <br /> Address City State ;EIVED <br /> Phone Phone Email TAR' O 6 �Q <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge+ <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or iA <br /> form. 0 � <br /> I also certify that I have prepared this applicatiotyand t t th ork to be performed will be done in accordance with all SAN JOAQUIN COUNTY OrdmLI4.-es, <br /> Standards,STATE and FEDERAL laws. r j <br /> 3 2 <br /> APPLICANT'sSIGNATURE: DATE: "-�_ � <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ® OTHER AUTHORIZED AGENT 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 By Assigned To Linked FA ID <br /> Date PE Fee Record Number <br /> ❑Cash Check# ` ❑Confirmation# Payment <br /> Received By <br /> Rev 07/10/2024 <br />