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❑ New Facilliity,, X Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Speedway #4873 <br /> Site Address City State ZIP <br /> 35 N. Cherokee Lane Lodi CA 95240 <br /> APN Supervisor District <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner 0 Repairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> Comments <br /> UST Repairs <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner xi o t meto ❑ Architect <br /> required ; IS�� <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ® Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> Walton Engineering, Inc 617238 ABHaz <br /> Address City State ZIP <br /> P.O. Box 1025 'Nest Sacramento CA 95691 <br /> Phone Phone Email <br /> 916-373-1166 <br /> ❑ Billing Party Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> Speedway LLC <br /> Address City State ZIP 45501 <br /> P.O. Box 1510 Springfield OH <br /> Phone Phone Email <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Arcfi yIn-c <br /> First Name Last name If contractor, indicate type and license VF <br /> Address City State S ZIPJ �OGJ <br /> Phone Phone Email r l�/V (// J <br /> yE �THRpNM'CoUNT <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or prof j <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 be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. ���� � �2 QL !L <br /> APPLICANT'S SIGNATURE: DATE: 03/11/2025 <br /> ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Contractor <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 /> Accepty4y, Assign Assigno To Linked FA ID <br /> G( i� ��0 D 36 C <br /> Date 120-5TE O 5 + /�_ Record Nu 3 Ra5mm951 <br /> ❑ Cash Check# ✓ Confirmation# 11 'l7 0-93 Payment <br /> / 2[ Received By/ <br /> Rev 07/10/2024 ¢1�7,�L1 <br />