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10 New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> OLSON TRUST PROPERTY <br /> Site Address City State ZIP <br /> 125 East Lodi Avenue Lodi CA 95240-2906 <br /> APN Supervisor District <br /> 043-063-080-000 <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner ❑ Repairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ® Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Cont'actor ❑Architect <br /> required <br /> ® Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑Architect <br /> First Name Benjamin Khatirine���� �Last name If contractor, indicate type and license number <br /> ° <br /> Address City State ZIP <br /> 14749 North Thornton Road Lodi CA 95242 <br /> Phone Phone Email <br /> (916) 261-6194 benkhatirine@gmail.com <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑Architect <br /> First Name Last name If contractor, indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑Architect <br /> First Name Last name If contractor, indicate type and license number <br /> Address City State ZIP <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 rk to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws.APPLICANT'S SIGNATURE: DATE: 08/27/2024 4 <br /> El PROPERTY/ BUSINESS OWNER ❑ OPERATOR/MANAGER OTHER AUTHORIZED AGENT <br /> Title fp <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required p h*114L / ��.+p�, �A— <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the above site address,hereby authorize thef <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 PE /1 Fee f Record Number 462 <br /> /� Payment ` <br /> ❑ Cash El Check# Confirmation# 1 $ V,?a Received By <br /> Rev 07/10/2024 <br />