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❑ New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name Chevron 307709 <br /> Site Address 10858 Trinity Parkway city state ZIP <br /> Stockton CA 95219 <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner DO Repairs or Remodel ❑Other <br /> Requested Operating Permit <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 I&Contractor ❑Architect <br /> required <br /> filling Party ❑Facility Owner ❑Facility Contact ❑Property Owner Contractor -/` v r <br /> rchitect <br /> First Name Last name If contractor,indicate type and license number <br /> Becky Galle o 794519 <br /> Address City State ZIP <br /> 7050 Village Dr Suite D Buena Park CA 90621 <br /> Phone Phone Email <br /> 657 262-8195 BGalle o Fast achus.com <br /> Billing Party Facility Owner ❑Facllity Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Chevron 307709 <br /> Address City State ZIP <br /> PO BOX 6004 San Ramon CA 94583 <br /> Phone Phone Email <br /> 925 842-9002 DRowe@ChevrDn.com <br /> ❑Billing Party ❑Facility Owner ❑Facllity Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and limp <br /> Address City State ZIP <br /> APR 114 <br /> Phone Phone Email <br /> AN JOq <br /> O NTy <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all si a <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 T <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. _II.. <br /> APPLICANT'S SIGNATURE: ` DATE: 3/31/25 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER [R OTHER AUTHORIZED AGENT Permit Specialist <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 tome or my representative. <br /> Accep By Assign d To Linked FA ID <br /> �, �u 7-73 7 <br /> Date PE Fee Record Number <br /> ��C toI + I Ra5©P59(OCo <br /> .i Imp, -tL; bpi fiA a W.� I q 9 t)32o5J <br /> Rev 06/12/2024 �Q,� <br /> 2 RooS appb4/ <br /> 1 / I <br />