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❑ New Facility Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name Arco 2186 Site Address City State ZIP 3212 North California St Stockton CA 95204 APN Supervisor District First Name Last name If contra or, Indicate type and license number Travis 125-320-01 1073967 Address 6805 Sierra Court Suite G City Dublin State ZI P 94568 Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner 0 Repairs or Remodel ❑ Other Requested Operating Permit 925e551 s7655 Comments 87 grade Slave STP Sump repair If mobile food truck or License Plate Number VIN pumper truck Contact Types iiling Part ❑Billing Party ❑ Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect required If contractor, indicate type and license number RANDALL LdAIOr State First Name Last name y ❑ Billing Party acility Owner Facility Contact 11 Property Owner ❑ Con ❑Facility Owner ❑Facility Contact ❑Property Owner Contractor ❑Architect First Name Last name If contractor, indicate type and license number RANDALL LdAIOr State First Name Last name If contra or, Indicate type and license number Travis Bowen 1073967 Address 6805 Sierra Court Suite G City Dublin State ZI P 94568 Email CA Phone Phone Email 925e551 s7655 Travis.Bowen@ Westco.com ❑ Billing Party ❑Facility Owner ❑Facility Contact FO Property Owner 11 Contractor ^/ tractor ❑Architect First Name Last name If contractor, indicate type and license number RANDALL BROWN State Address City State ZIP P.O. Box 6038 Artesia CA 90702 Phone Phone Email 530.777.8942 randall.brown1@I)p.com BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all s"'J ^/ ❑ PAh�ept_ First Name Last name If contractor, indicate type a � er ,, Address City State ION IY 20,� Phone Phone Email J OgQU/N ,� ��N� specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on form. 1 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 laws. I 4 ?� APPLICANT'S SIGNATURE: DATE: 6/17/2025 ❑ PROPERTY /BUSINESS OWNER ❑OPERATURI MANAGER ❑OTHER AUTHORIZED AGENT PERMIT TECHNICIAN (AGENT OF CONTRACTOR) 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 To � Id-LL�'r��n p� Linked FA ID ( Rev 07/10/2024 ^/ i✓ ' Date/„ V� S PE 7�UK Fee 4'L210 Record Number 5 19 9 S R a ❑ Cash ❑ Check # Confirmation # /� Payment o��E/�j0%rZ� Received By Rev 07/10/2024