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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Chevron 201761 <br /> Site Address City State ZIP <br /> 1103 S . Main St . Manteca California 95337 <br /> APN Supervisor District <br /> nsultation ❑ Change of owner 64 Repairs or Remodel ❑ Other <br /> Requested Operating Permit Type of Service ❑ Application for Ti� <br /> Comments SB989 repairs — UDC 1 /2 <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑ Billing Party ❑ Facility Owner ❑ facility Contact ❑ Property Owner La Contractor ❑Architect <br /> required <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner 0 Contractor ❑Architect <br /> First Name Last name If contractor, indicate type and license number <br /> Alan Evans 300345 A B C61 /D40 HAZ <br /> Address City State ZIP <br /> 8281 Commonwealth Ave Buena Park California 90621 <br /> Phone I Phone Email <br /> 714 826 0352 562 231 8221 aevans@wpinc 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 <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. <br /> I also certify that I have prepared this a he work t be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards, STATE and FEDERAL laws. 12 / 12 /2 0 2 4 A ypp <br /> APPLICANT'S SIGNATURE: DATE: <br /> ❑ PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER 12 OTHER AUTHORIZED AGENT <br /> Title <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required q <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, 1 % thorize the <br /> release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONME �/fa{, T <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. HH ROAt - Co <br /> ry <br /> Accepted "y (( � �N Assigne To_n �,o k1 y Linked FA ID OO <br /> Date` „ J PE Fe" 1 1 2— �.L 1�� C�� Record Number <br /> rG I 2 Z-J�q <br /> ❑ Cash ❑Check H 1�Confirmation p Payment <br /> 1 Received By <br /> Rev 07/10/2024 <br />