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❑ New Facility ❑ Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name The Restomod Shop Site Address City Stockton State ZIP 95205 2461 North Wilson Way CA APN 11707053 Supervisor District Type of Service ❑ Application for nsultation ❑ Change of Owner ❑ Repairs or Remodel r Requested Operating Permit Comments Work Plan for Site Mitigation Well Boring Permit VIN If mobile food truck or License Plate Number pumper truck Contact Types l Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect required Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner Contractor [b—Architect (Cons Itant First Name Last name If contractor, indicate type and license number Madison Kennedy Address 2500 Camino Diablo city Walnut Creek StateCA ZIP 94597 Pho Phone Email 5.746.6000 937-829-9031 mkennedy@aeionsultants.com ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner X contractor ❑ Architect First Name Last name contractor, indicate type and license number If Kenneth Cooke C-57 License If Address 3011 Twin Palms Drive city Aptos State CA ZIP 95003 Phone Phone Email 831-662-8178 ❑ Billing Party ❑ Facility Owner ❑ Facility Contact IV Property Owner ❑ Contractor ❑ Architect First Name Restomod Properties LLC N/A Last name If contractor, indicate type and license number Address 4601 Greenoak Lane city Stockton State CA ZIP 95212 Phone N/A Phone Email 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. APPLICANT'S SIGNATURE: 1% DATE: 11/20/2024 ❑ PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER IXOTHER AUTHORIZED AGENT Staff Scientist.I 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 �, Assigned To Linked FA ID 4✓ c,/ 4y� _ Date I ZJIEC 2� U Fee Record NumberR2400W &PaymentElCash heck# ❑Confirmation k ` l t � `7 y U Received By L` Rev 07/10/2024