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❑ New Facility Existing Facility
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<br />San Joaquin County Environmental Health Department
<br />Application Form
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<br />1•acilily Name
<br />IArco AmPm
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<br />15,to Address city
<br />110715 Trinity Pkwy Stockton
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<br />upervisor Distill
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<br />to] AlmicN1tJnliar I I CUIN.,atellon L I (6hatlge of 0*71& „-^
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<br />91 �OPW in sump bucket was replaced 12/12/2074 due to a reoccurring ISO vapc
<br />If mobile food truck or I cense Plata Number - VIN
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<br />pumper truck
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<br />WNtrr r`iutlr 1 I J a%irkiii1v Owner FacihSO%ly Gontarl L'1 Profalrty OwnrSir
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<br />AddrlI Phoiii - rPYgne P,rnAil _._..__otpzz. to ill I11
<br />CA 1 9521.9
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<br />izl Repairs or Remodel
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<br />R Architect
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<br />If contractor, Indicate type and license number
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<br />1 wu,u;, P}r±y L] f acr!ky t7ivnrr• !,� Erit:gity tcrrtatt t 1 i3roperty Owner � »�u� Contractof — � •� �-~�r L'1 Architect � � � •- •
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<br />` "tt Nant`' Lati T13RrA If contractor, Indicate type and license number i
<br />BZ Maintenance" 433159 A B C-61 D40
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<br />PO Box 9331��
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<br />.. 1►1/:elr�rTttntaCAto 95891
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<br />i r. fir1`f+rtspi4rCtl`>TiGngt. Iloniractot 11 Architect
<br />iFirst Name A. L,F �+ .-..i . Ohio.. ...,,..,. q% dOpe 4%l 0 OF�-.....,_�....__.._. .. __ 1
<br />t (Al - if contrutixvildlcate type a umber IF
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<br />Atldress City 511*h ���� 1
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<br />i BILLING ACKNOWLEDGEMENT: 1, the undersigned property or business owner, operator or authorized agent of same, acknowl�lhctlb(a
<br />/�..ect
<br />specif:c f. NVIRONMI NTAL HL'AI r1i Ot PAR rMf N I hourly Charges associated with this project or activity will be billed to lne or m a�
<br />I form
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<br />I also certify that I have prepared this application and (flat the work to be performed will be done in accordance with all SAN JOAQUIN COl N�pO�ri�16�des
<br />Standards, SIAL I and f EOCRAL law<,
<br />APPLICANT'S SIG NATURE: _ _ ! • _ • lutV_. _ DATEOFF:
<br />i
<br />Ximill PROPI R1Y / B1151NL'SS UWNI R NON RAI OR / MANAGER C] OrHI R AUl IfORIZCO AGEN r �'� ate, %06 J'' i
<br />ritic
<br />If APN IC AN r e, raiz the BILLINU PAR I Y. proof of authorwoiiion to scan is required '
<br />AUTHORIZATION TO RELEASE INFORMATION: (Novi( applicable. is the owner or operator of the property located at the above site address, hereby authorize the
<br />j release of any and all results, Eootechnfcal data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH TT
<br />.:11.pmi I tuft N1 :B Loorh it tS'avai!atili! atld :tt 00 9amo tIMik II. tF drowsed tome or my representative_
<br />_» _ ._ . 4,000 _. _
<br />1 Accepted By Asst ed to ` Linked FA IDFAA
<br />CA l !1
<br />I Date ._-.. `� PE F . e .Retard Ill' F: a�• L/
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<br />lJ t:a,h dpayment WI~
<br />2 O Confirmation q_ 00,0 0_ , __»frCheck
<br />_...._..35373 -_. ,_ . ,.;1 Received By _� !
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