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PAYMENT n Joaquin County-Environmental Health Departmi RECEIVED 1868 c.Hazelton Avenue-Stockton CA 95205-Phone: 209-a.,.,3420 JUN 01 2022 APPLICATION SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH ENVIRONMENTAL PERMIT TO OPERATE HEALTH DEPARTMENT EMPLOYEE HOUSING OR LABOR CAMP ❑New Camp ❑Conditional Permit ❑ Multiple Years(Permanent Housing Camps only) ❑Annual Permit for Calendar Year C>W P-j Amended Permit: *Change of Operator *Change of Owner *Change of Operator.Address *Change of Owner Address Permit ID#: 0027506 *Additional Employees State ID#: EH ID#: Please Note any Corrections or Changes in Facility/Operator Information directly on this form. Site Name: MOTEL 6 Location: 2654 W MARCH LN,STOCKTON Operator: BARRERA,LUIS Mailing Address: 17450 AVENIDA LOS ALTOS,SALINAS CA 93907 Facility Phone#:(831)229-0682 Legal Owner: RANCHHODRAI INC New Owner? ❑Yes ❑ No Owner Address: 4219 E WATERLOO RD,STOCKTON CA 95215 Owner Phone#:(831)229-0682Ext:LUIS Community Facilities Provided by Camp: Community Kitchen? ❑ Yes ❑ No Men: Number of Toilets Number of Showers Number of Lavatories Women: Number of Toilets Number of Showers Number of Lavatories Housine Accommodations to be Utilized this Year: Occupancy Dales: Buildines Employees Dormitories from-/-/-to_/_/ Crop SF Dwellings from /_/ to_/_/ Crop Apartments Owner Owned MH/RV Total Number of Days to be used this Calendar Year: Owner Owned RR Cars Total Days Occupied by 25 or more Employees: MH/RV Spaces Note TOTALS Camps occupied by 25 or more Employees for 60 or more days in a year Require a PUBLIC WATER SYSTEM Permit ❑Inactive 1 mpuria nt: I n order to protect your land use status,if camp will not be used this year but is intended for use in the future,Check this Box and return this application. Fee Schedule ❑ Permanent Camp Annual Permit Fee S50.00+ Number of Employees @$15.00 each=$ ❑ Transfer of Ownership $25.00=S Permanent Amendment Fee $25.00+ Number of Additional Employees _ @$15.00 each=$ �] Late Application Fee $100.00+ Number of Employees @$30.00 each=$ Fee must be submitted with Application 1--, o✓r TOTAL FEE DUE$ 4' Remit TOTAL FEE as CALCULATED ABOVE in the ENCLOSED Self-adressed Envelope MAKE CHECKS PAYABLE to EHD Applicant agrees to all necessary inspections incident to issuance of a PERMIT TO OPERATE. Applicant agrees that this project (camp) shall be operated and maintained in accordance with the applicable provisions of the EMPLOYEE HOUSING ACT, Chapter 1, Part 1, Division 13 of the California Heatdr and Safety Code and Chapter I,Subchapter 3,Title 25,California Code of Regulations. Applicant Name 1 �� r-r.e Title ( V�Qr ❑Paruurship (Please PRINT or TYPE) ❑Corporation Address ( Lf ( nj 4`3111—7 Phone Q21 '13-1 `0(0`6�- Applicant Signature Date of Application+ ds- ;- d2a - Amount Paid Date of Payment Type Chec Receipt# Received By Account ID 0049218 Facility ID Program Record ID PIE Assigned to PWS ID FA0025973 PR0545930 2755 9834-SUSZYCKI N/A Repos#:7066 Application Printed:3/112022