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❑ New Facility d Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name Port of Stockton / Shed 7 - East Complex Site Address City State ZIP Port Road 4 & Port Road B Stockton CA 95201 APN Supervisor District 14502004 District 1 Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner ❑ Repairs or Remodel EZ Other Requested Operating Permit Comments Boring permit application for UST Closure in Place proposal If mobile food truck or License Plate Number VIN pumper truck N/A N/A Contact Types TT5 Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑Architect required ❑ Billing Party ® Facility Owner ® Facility Contact7 Property Owner ❑ Contractor ❑ Architect First Name Last name If contractor, indicate type and license number Port of Stockton Address City State ZIP 95203 2201 West Washington Street Stockton CA Phone Phone Email 209-946-0246 jcashman@stocktonport.com Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect First Name Last name If contractor, indicate type and license number Geosyntec Consultants Address City State CA ZIP 94612 1111 Broadway, Floor 6 Oakland Phone Phone Email 510-285-2795 awicke@geosyntec.com ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner Sdcontractor ❑ Architect First Name Last name If contractor, indicate type and license number Gregg Drilling Gregg: 1044456 Address City State ZIP Phone 925-313-5800 Phone Email (Gregg) dmoses@greggdrilling.com 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. " ' iA j�,I_ 9/6/2024 APPLICANT'S SIGNATURE: l:' DATE: ❑ 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 By �VAJ Assigned To Linked FA ID DatMo �� PE Fee 4+ Record Number 24-00 � 9C.T ❑ Cash ❑ Check# Confirmation# Q Q Ij T Payment ll// CUJ Received By Rev 07/10/2024