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❑ New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name Raleys <br /> Site Address 4219 Morada lane City Stockton State CA ZIP 95212 <br /> APN Supervisor District <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner x Repairs or ❑ Other <br /> Requested Operating Permit emodel <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑Architect <br /> required <br /> Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner xx r�treetvr� ❑ Architect <br /> -t 4CLs`f� <br /> First Name,Able MaintenanceXnC, Last name Tran If contractor, indicate type and license number <br /> Chrisina 312844, B A C10 HAZ <br /> Address 3224 Regional Parkway City Santa Rosa State CA ZIP 95403 <br /> Phone 408-213-6039 -]--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 Party ❑ Facility Owner ❑ Facility Contact - El Property Owner ❑ Contractor Ell Architect <br /> —__ --._ . .._. I--- - -._— .. _. <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 applicati n 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// -/01 <br /> APPLICANT'S SIGNATURE: 11 �-'t �J DATE: j/�F / �/2(]� / 1 <br /> ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT T r^ 'C L4__ j-ermt j <br /> Title Cvvrr-�<�'� <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 th <br /> release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALT) <br /> DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. // c <br /> Accept By /� Assigned To type Linked FA ID n1'I �� F v 40�7 <br /> (! W V/ �� QUi C <br /> Date mb Fee PE Record Nuer <br /> r 2 30 `� a —S R a 4 00 (DCo FpMFN <br /> Rev 06/12/2024 OCR : I q It ✓Z6 70 <br />