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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name Wells Fargo Property <br /> Site Address 303 North El Dorado Street city Stockton State CA ZIP 95202 <br /> APN I Supervisor District <br /> 139-080-03 0 <br /> Type of Service ❑Application for Consultation ❑Change of Owner ❑ Repairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> Ilix <br /> Comments _ Work Plan and permit - �t-O r C—V u,Y&y,VYw,kA 1 5 zc,Sa1 ro Stil rf <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 Carla Last name Perkins If contractor,indicate type and license number <br /> Address 1755 Grant Street, 4th Floor c�tyConcord State CA ZIP <br /> 94520 <br /> Phone Phone Email <br /> 415-407-6905 Carla.J.Perkins ellsfar o.com <br /> jaf Billing Party ❑ Facility Owner ❑Facility Contact ❑Property Owner Contractor ❑Architect <br /> First Name Last name Helge If contractor,indicate type and license number <br /> James Consultant <br /> Address cityyt State CA ZIP 95670 <br /> 3130 Kilgore Road STE 200 Kancho Cordova <br /> Phone Phone Email, <br /> 916-366-2308 1 Ihelge@kleinf Ider.com <br /> ❑Billing Party ❑Facility Own ❑Facility Contact ❑ Property Owner ❑Contractor ❑Architect eG <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP TO <br /> tea. <br /> Phone Phone Email <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 this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. "�'e 0_e_ <br /> APPLICANT'S SIGNATURE: � �7 DATE: 11/12/2024 <br /> ❑ PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER PLOTHER AUTHORIZED AGENT tAitskill:awjl(- <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 Q — Assigned To _ Linked FA ID <br /> Date <br /> It ( t r) � PE -lot �-p Fee US Record Number -SRo1400041 <br /> O Cash ❑Check q �conFlrma[ion It ?3j Payment <br /> I °t 7i Received By <br /> Rev 07/10/2024 <br />