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❑ New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Quick-n-Save#1 <br /> Site Address 1901 S. El Dorado St city Stockton State CA ZIP 95206 <br /> APN Supervisor District <br /> 165-080-19 C� <br /> Type of Service ❑Application for Consultation ❑Change of Owner ❑Repairs or Remodel M Other <br /> Requested Operating Permit WP Review <br /> Comments lUl/ti- �6{ � �t �� L'.�1 V1 �� �-� ���- .1-��j•l�iC'(��LL�--6� <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ',Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ®Contractor ❑Architect <br /> First Name FREY Environmental Last name If contractor,indicate type and license number <br /> A Haz 643673 <br /> Address 1336 Brommer St city Santa Cruz State CA ZIP 95062 <br /> Phone Phone Email J' <br /> 831/464-1634 408/859-6567 terrykinn@freyinc.com r <br /> �l <br /> 2 Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Terrence Last name Kinn If contractor,indicate type and license number <br /> Address 1336 Brommer St City State ZIP <br /> Santa Cruz CA 95062 <br /> D <br /> r-• <br /> Phone Phone Email <br /> 408 859-6567 terrykinn@freyinc.com <br /> c: <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> r <br /> First Name Rajinder Last name Sharma If contractor,indicate type and license number <br /> Address 33215 Falcon Dr. City State CA ZIP <br /> Fremont 94555 <br /> Phone Phone Email <br /> 510-825-5251 2rajindersharma@gmaii.cc m <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 tha rk to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. ��- <br /> APPLICANT'S SIGNATURE: _ ---+ DATE: 12/9/24 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER IN OTHER AUTHORIZED AGENT Project 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 Assi d Linked FA ID <br /> VDIIA <br /> Date PIE y Fee Record Number <br /> ❑Cash ❑Check# ❑Confirmation# Payment <br /> Received By <br /> Rev 07/10/2024 <br />