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❑ New Facility Existing Facility <br /> (needs SR#) <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name 7-ELEVEN #43208/59228 <br /> Site Address City State ZIP <br /> 2705 COUNTRY CLUB BLVD STOCKTON CA 9 5 a o 4 <br /> APN Supervisor District <br /> iai - ato - o8 <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner lI Repairs or Remodel ❑ Other <br /> Requested Operating Permit I y� p� <br /> Comments -j�sf t I Mp[au „' _, + <br /> r <br /> mobile foodtruck or License Plate Numberlmper truck <br /> Contact Types @ Billing Party ❑ Facility Owner IN Facility Contact ❑ Property Owner ® Contractor M Requestor <br /> required <br /> Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner Contractor ❑ Architect <br /> 1qe .s-NY <br /> First Name Last name If contractor, indicate type and license number <br /> STEPHANIE CHARISSA 312844 A, B, CIO, HAZ <br /> Address City State ZIP <br /> 3900 COMMERCE DRIVE WEST SACRAMEN O CA 95691 <br /> Phone Phone Email <br /> hone 3-3857 ste haniec@servi stations stems.co <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 Email <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> PAY <br /> Address City State CE�V�D <br /> Phone Phone Email ryn <br /> cq Gfl <br /> ENV -1N co <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge t a A,tlte, 4/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. //� - <br /> APPLICANT'S SIGNATURE: Lt� c,,�K��^(.S� DATE: 10/08/25 <br /> ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/MANAGER MOTHER AUTHORIZED AGENT OPERATIONS MANAGER <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 „e� Assigned To , qStt� Min n Linked FA ID <br /> A Mal 2�} <br /> yi <br /> Date (ry 25 PE 5 0q Fee I �q in �1�Y'Y ll.' Record Number � ^ � � A I 5� \9 <br /> ❑ Cash L ❑ Check# Confirmation # L /n Payment <br /> Received By <br /> Rev 07/10/2024 2 of 6 <br />