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❑ New Facility ® Existing Facility San Joaquin County bnvironmental Health Department Application Form Facility Name port of Stockton / Rough and Ready Island Site Address Rough and Ready Island W Fyffe Street city Stockton stdte CA ZIP 95203 APN 16203007 Supervisor District Type of Service Q Application for ❑Consultation 0 Change of Owner ❑Repairs or Remodel [St Other Requested Operating Permit Comments Monitoring well destruction permit application VJ If mobile food truck or License Plate Number VIN pumper truck Contact Types n Billing Party ❑ Facility Owner 0 Facility Contact El {'rQpc D Contractor ❑Architect required ❑ [filling Party n F dlity Owner Li Facility Contact �R('roperty Owner 13 Contractor d Architect First Name Port of Stockton Last name if contractor,Indicate type and license number Address 2201 Washington Street cityStockton State CA ZIT' 95203 Phnn209-946-0246 Phone Email -T uLtilling Party ❑Facility Owner ❑ Facility Contact T❑ Pr operty Owner ❑ Contractor El Architect First Name Geosyntec Consultants, Inc. LasL name If contractor,indicate type and license number Address 3043 Gold Canal Drive, Suite #100 City State CA ZIP 95670 Rancho Cordova %r6-205-6833 r'Il�nr Email Csillin�;3arrr ❑ Facility Owner CI Facility Contact fa Property Owner CI Contractor ©Architect Fir:it idame Last name If contractor,indicate type and license number Address city State ZIP Phone Phone Email BILLING ACKNOWLEDGEivIENT: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. ` 9/18/24 APPLICANT'S SIGNATURE: DATE: _ ❑ PROPERTY/ BUSiNESS OWNER ❑OPERATOR/MANAGER IN OTHER AUTHORIZED AGENT Billing party 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 � v v Assigned To Linked FA ID IF Date /zD Zo/ PE / Fee ) Record Number C�' k2 '1 b b ❑ Cash ❑Check# )kanflrmation# f g 43 -iv Payment Received By � Rev 07/10/202.4