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Cop <br /> ❑ New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Former Viktron Property <br /> Site Address City State ZIP <br /> 1443 N vv Drive Stockton CA 95206 <br /> APN Supervisor District <br /> 163-300-230-000 J <br /> Type of Service ❑Application for Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> Work Ian Review -cV <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 T <br /> Property Owner Contractor ❑Architect <br /> /Consultant <br /> First Name Last name If contractor,indicate type and license number <br /> Ramin Bet-Yonan <br /> Address City State ZIP <br /> 3338 Hadsell Ct. Pleasanton CA 94588 <br /> Phone Phone Email <br /> 925-998-3905 rbetyonanagr riail.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 7- Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑ <br /> First Name Last name If contractor,indicate type a&1IQrUft1,b <br /> Address City State $� Zt ;,j) 9 2026 <br /> Phone Phone Email / <br /> N y��JUI�{ NllICAJIV7Y <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or 8tVr <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./���APPLICANT'S SIGNATURE: 9iLQ.ili // DATE: June 10, 2026 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER tdOTHER AUTHORIZED AGENT Consultant <br /> Title <br /> If APPLICANT is not the BILLING 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 11 <br /> tTe r 1 Record Number 1 <br /> PE U Fee 3 I' s�� (: 2G�f <br /> ,Zt ,� Payment <br /> ❑Cash �Check q ❑Confirmation N Received By <br /> Rev 07/10/2024 <br />