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❑ New Facility f Existing Facility San Joaquin County Environmental Health Department wtdc' Sf� Application Fora Facility Name Fast & Easy #60 Site Address City State ZIP 10878 N Hwy 99 Stockton CA 95212 APN Supervisor District Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner Repairs or Remodel ❑ other Requested Operating Permit Comments See application for Scope of Work- Need to replace within 7 days If mobile food truck or License Plate Number VIN pumper truck Contact Types ❑ Billing Party ElFacility Owner ElFacility Contact ❑ Property Owner ntractor ❑ Architect required P�IkBilling Party ❑ Facility Owner El Facility Contact ❑ Property Owner Contractor ❑ Architect First Name Last name If cont ctor, indicate type and license number - Cindy Cadacio-Chan 958763 A Address City State ZIP P.O. Box 1394 Lafayette CA 94549 Phone Phone Email 925-499-6294 permits@ecochek.com ❑ Billing Party ❑ Facility Owner ❑ Facility Contact 7 Property Owner ❑ Contractor ❑ Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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, Standards,STATE and FEDERAL law APPLICANT'S SIGNATURE: DATE: 10108@5 ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/MANAGER 9 OTHER AUTHORIZED AGENT Ofce/ausiness Affairs Manager Title If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION:When applicable, I,the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Accepted Assigned o in` Lv eZ Linked FA ID � I 99 1 r rr� �J ecord Number (d f"l ZV JP ��O � Fee 5 / o c S �' Payment ❑ Cash Check# ❑ Confirmation# Received By Rev 07/10/2024