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❑ New Facility IN Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name port of Stockton/ Rough and Ready Island Site Address Rough and Ready Island W Fyffe Street City Stockton state CA ZIP 95203 APN 16203007 'supervisor District Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel Mother Requested Operating Permit Comments Monitoring well destruction permit application If mobile food truth or License Plate Number VIN pumper truck Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact IJ Property Owner ❑Contractor ❑Architect required ❑Billing Party ❑Facility Owner ❑Facility Contact M Property Owner ❑Contractor =A,-c -7 First Name port of Stockton Last name if contractor,indicate type and license number Address 2201 Washington Street eityStockton state CA ZIP 95203 Phon�09-946-0246 Phone Email fXRilling Party ❑Facility Owner ❑Facility Contact ❑Property owner ❑Contractor ❑Architect First Name Inc Last name If contractor,indicate type and license number Geosyntec Consultants, Addrnss 3043 Gold Canal Drive, Suite#100 ty State ZIP �ancho Cordova CA 95670 '�In§-205-6833 Phone ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect First Name Last name If contractor,indicate type and license number Address City State ZIP Phase Phone Email BILLING ACKNOWLEDGEMENT:1,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. APPLICANrs SIGNATURE: � DATE: 9/18/24 ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER 13 OTHER AUTHORIZED AGENT Billing party Title If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required AUTHOR17-ATION 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 Assigned To Linked FA ID Date PE Fee Record Number Payment Q Cash b CheEk# ❑Confirmation 4 Received By Rev 07/10/2024