SR2602168 - Laserfiche WebLink

Home Browse Search

❑ New Facility ® Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name Olin Chlor Alkali Site Address City State ZIP 26700 South Banta Road Tracy CA 95304 APN Supervisor District 252-150-080-000 5 Type of Service ❑Application for fConsultation ❑Change of Owner ❑Repairs or Remodel ®Other Requested Operating Permit / Comments Destruction of monitoring wells MW-5, MW-9, MW-10, MW-11, MW-12, MW-13, MW-14, and MW-15 If mobile food truck or License Plate Number VIN pumper truck Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect required ❑Billing Party 0 Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect First Name Last name If contractor,indicate type and license number Dane Grimshaw Address City State ZIP 490 Stuart Road NE Cleveland TN 37312 Phone Phone Email (408) 599-4030 DRGrfmshaw@olin.com B Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect First Name Last name If contractor,indicate type and license number Jessica Ramirez Address City State ZIP 1111 Broadway, 6th Floor Oakland CA 94607 Phone Phone Email (510)285-2682 JRamirez@geosyntec.com ❑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 Phone 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 1 have prepared this application and that t rk to be x1formed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Standards,STATE and FEDERAL laws. APPLICANT's SIGNATURE: t w DATE: _5/15/2026 ❑PROPERTY/BUSINESS OWNER ❑)OP RATOR/MANAGER ®OTHER AUTHORIZED AGENT Jessica Ramirez,Senior Engineer,Geosyntec Consultants 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 Date PE Fee Record Number ` ❑Cash ❑Check# t7 Confirmation q l� L, Payment Received By A Rev07/10/2024 ^6�� Qa05� ,/