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tMARW111WIWRlIY7lrai�fws�n7wig aaw.s.w�o�..�� <br /> ❑ New Facility © Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name ------------ <br /> lakeisrood Plaza <br /> Site Address City State ZIp <br /> 106 8k-108 North Ham lane Lodi CA 95242 <br /> APN Supervisor District <br /> 03;-100--W <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel i ®Other <br /> Requested Operating Permit <br /> Comments ',oil Boring Permit , <br /> ok vie-,k 5 <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 Last name If contractor,indicate type and license number <br /> Michael G u rev <br /> Address City State ZIP <br /> 1818 Grand Canal Boulevard,Suite 4 Stockton CA 95207 <br /> Phone Phone Email <br /> 916-527-8234 mgurev@freeman6rm.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 /> Daniel Villanueva C57:1063765 <br /> Address city State ZIP <br /> 837 Shaw Road Stockton CA 95215 <br /> Phone Phone <br /> 8W-511-9300 d Email <br /> villanueva@advancedTb- <br /> - <br /> M Billing Party ❑Facility Owner ❑Facility Contact ®Property Owner ❑Contractor ❑Architect <br /> i <br /> First Name Last name If contractor,indicate type and license number <br /> John Godi <br /> Address city State ZIP <br /> 4285 Spyres Way Modesto CA 9�� <br /> Phone Phone Email <br /> 209-577-,280 johngodi@sundancecn com <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. 06/2 3/r0r5 <br /> APPLICANT'S SIGNATURE: DATE: <br /> M PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT _ <br /> Title <br /> If APPLICANT is not the BIWNG 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 PE Fee �L Record Number <br /> ��z�l � � ���� � <br /> ❑Cash ❑Check# Payment <br /> d Confirmation# D`'� �°�`� Received By <br /> Rev 07/10/2024 <br />