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❑ New Facility Existing Facility <br /> (needs SR#) <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> 7-ELEVEN#46641 <br /> Site Address City State ZIP <br /> 2500 W LODI Me. LODI CA q 5 0- 4 t;Z <br /> APN Supervisor District <br /> oal- 4 00 -o <br /> Type of Service ❑Application for ❑ Consultation ❑ Change of Owner 10 Repairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> Comments <br /> Dl- 9901U,r cgLaujnt4+ <br /> ripf <br /> mobile food truck or License Plate Number VIN <br /> mper truck <br /> Contact Types RI Billing Party ❑ Facility Owner ® Facility Contact ❑ Property Owner ® Contractor M Requestor <br /> required <br /> Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner Contractor ❑ Architect <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 SACRAMENTO CA 95691 <br /> Phone Phone Email <br /> 916-343-3857 stephaniec@servicestatio systems.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 --[Email 0 <br /> mm � <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor hi ct. L.L <br /> O v <br /> First Name Last name If contractor, indicate type and° Ase er <br /> Address City State ZI P <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. <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. L_ 1 !- -- <br /> APPLICANT'S SIGNATURE: s ohim.>(i�' dw"'S�/ DATE: 10/08/25 <br /> ❑ PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ® OTHER 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 B3' . 6[ I�'\ n Assigned T �yi� �� Linked FA ID o0� <br /> Date `O �'� JE'] <br /> V C/r Fee Record Numbe <br /> f � 2�p� � 1 sTZas0 15 -74- <br /> 0 Cash heck# Confirmation#2 V bvc I Payment �1 1 <br /> Received By CA,.,, <br /> Rev 07/10/2024 2 of 6 <br />