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❑ New Facility $l Existing Facility <br /> (needs SR#) <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> 7-ELEVEN#41531 <br /> Site Address City State ZIP <br /> 3379 N TRACY BLVD TRACY CA 95376 <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner 60 Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> REPLACE 87 SPILL BUCKET(WORK COMPLETED ON 06/06/25) <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types RI Billing Party ❑Facility Owner ®Facility Contact ❑Property Owner ®Contractor ® Requestor <br /> required I J <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner 0 Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> STEPHANIE CHARISSA SERN ICE STATION SYSTEMS INC 485184 C61/D40,B,HA Z <br /> Address City State ZIP <br /> 3900 COMMERCE DRIVE WEST SACRAMENTO CA 95691 <br /> Phone Phone Email <br /> 916-343-3857 st phaniec@servicestationsyst ms.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 /> Address City State ZIP <br /> Phone 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 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 application and that the work to W performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: 07/29/25 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR I MANAGER Kl OTHER AUTHORIZED AGENT OPERATIONS MANAGER <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 /> Accepted By Assigned To Linked FA ID <br /> Date PE Fee Record Number <br /> Payment <br /> ❑Cash ❑Check# ❑Confirmation# Received By <br /> Rev 07/10/2024 2 of 6 <br />