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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 /> 0(o(n- a - I 3 <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 /> pumpertruck I T <br /> Contact Types ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner IX Contractor ❑ Architect <br /> required <br /> I IL <br /> at Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner Contractor ❑ Architect <br /> Re a,urs�r <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 ❑ Facility 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@Chevr:)n.com <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and I <br /> C <br /> Address City State ZIP <br /> APR 04 <br /> Phone Phone Email <br /> %'1AN.J0A01 tip, <br /> O NTy <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner, operator or authorized agent of same, acknowledge that all si a @J1 <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on thisT <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. ,, —,I . . <br /> APPLICANT'S SIGNATURE: ` DATE: 3/31/25 <br /> ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/MANAGER IR 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 to me or my representative. <br /> Acce'pt\�l By Assign d To n� Linked FA ID <br /> mui <br /> Date PE Fee Record Number <br /> �?CS- ���I + - I R ;15 ©l5q (P Co <br /> �.i Imp, �, o6fa � a W.-4 1g903-z 5] <br /> Rev 06/12/2024 �q,G � ���f I <br /> 2 goo5 1 <br /> permit- ptrlal � �t,ppU 4 <br />