Laserfiche WebLink
_z,C ❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> The Restomod Shop <br /> Site Address city Stockton State ZIP 95205 <br /> 2461 North Wilson Way CA <br /> APN 11707053 Supervisor District <br /> Type of Service ❑Application for nsultalion ❑Change of Owner ❑Repairs or Remodel • r <br /> Requested Operating Permit <br /> Comments Work Plan for Site Mitigation Well Boring Permit <br /> If moblle 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 1gl Contractor ❑Architect <br /> Consultant <br /> First Name Last name If contractor,indicate type and license number <br /> Madison Kennedy <br /> Address City State CA ZIP 94597 <br /> 2500 Camino Diablo Walnut Creek <br /> Ph0415.746.6000 937-829-9031 Email <br /> mkenned @aei onsultants.com <br /> ❑ Billing Party ❑ Facility Owner ❑Facility Contact ❑Property Owner N Contractor ❑Architect S <br /> i <br /> First Name Last name If contractor,indicate t pe and license number �. <br /> Kenneth Cooke C-57 License W1695970 <br /> Address 3011 Twin Palms Drive city Aptos State CA zIP 95003 <br /> Phone I Phone Email 4 <br /> 831-662-8178 > <br /> E <br /> ❑Billing Party ❑Facility Owner ❑ Facility Contact N Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number �— <br /> Restomod Properties LLC N/A r <br /> Address 4601 Greenoak Lane city Stockton State CA 2IP 95212 <br /> Phone N/A <br /> 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 activitywill be billed to me or my business as identified on this <br /> form. <br /> 1 also certify that 1 have prepared this application and that the workto be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. �,Arn�ry/, � <br /> APPLICANT'S SIGNATURE: " y' V DATE: 1 1/2012 024 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER EXOTHER AUTHORIZED AGENT Staff Scientist I <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 tl IZI /2� PE 2� v Fee g l� Record NumberSRa40m Co 1� 3 <br /> Payment <br /> ❑Cash O Checktl 4roconfirmation H 1 rq I I <br /> Received By . <br /> Rev 07/10/2024 <br />