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❑ New Facility Existing Facility <br /> San Joaquin County environmental Health Department <br /> Apphcation Form <br /> Facility Name <br /> 7-Eleven #46641 <br /> Site Address City State ZIP <br /> 2500 W. Lodi Ave. Lodi CA 95242 <br /> APN Supervisor District <br /> o a-i- +o - cp <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner 0 Repairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> Comments <br /> Replaced the 89 & 89 SC's on 7/22/24 <br /> If mobile food truck or License Plate Number VIN <br /> pumpertruck <br /> Contact Types ❑ Billing Party 0 Facility Owner ❑ Facility Contact ElProperty Owner 0 Contractor El Architect <br /> required <br /> Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner Contractor ❑ Architect <br /> First Name Last name If contra or, indicate type and license number <br /> Walton Engineering, Inc 617238 AB Haz <br /> Address City State ZIP <br /> P.O. Box 1025 \Nest Sacramento CA 95691 <br /> Phone Phone Email <br /> 916-373-1166 <br /> ❑ Billing Party Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> 7-Eleven <br /> Address Ci> allaS State ZIP <br /> P.O. Box 711 TX 75221 <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 /> Address City State ZIP <br /> Phone Phone Email <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/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. PAYM <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 COUNT LrLjjp g_esN <br /> Standards, STATE and FEDERAL laws. // KEEc ff V�EE <br /> APPLICANT's SIGNATURE: v a&&Mle� �� DATE: 07/09/25 <br /> ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/MANAGER 0 OTHER AUTHORIZED AGENT Contractor JUL' 17 20 5 <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title UN JOAQUIN CO NTY <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I,the owner or operator of the property located at the above site addres�� T release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRO L OMRTM NT <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br /> Acce d ByC 1` Assigned To, , /D Linked FA ID <br /> 15 <br /> D 10 �� PE n � � / + ' / Record Numbed a <br /> ❑ Cash ❑ Check#1 2Confirmation#f�503 /) 1, I Payment <br /> ` l Received By <br /> Rev 07/10/2024 D bi O- q ftOtlf I <br /> Puna H-L a <br />