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❑ New Facility ` Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Kwik Sery Boyett Petroleum #98 <br /> Site Address City State ZIP <br /> 2501 Jackson Ave Escalon CA 95320 <br /> APN Superviso(r�Disltrict <br /> A2 1' -7 1 J l <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner IR Repairs or Remodel ❑ M EN <br /> Requested Operating Permit <br /> 69--11 <br /> Comments <br /> S13 + 0 <br /> If mobile food truck or License Plate Number T <br /> IN "24 <br /> pumper truck S <br /> JN I <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor(JEp� �ITQ� <br /> required EF'ARj/yiE <br /> filling Party ❑Facility Owner ❑Facility Contact :1❑Property Owner Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> CGRS, Inc Matt Thomas A/HAZ 803616 <br /> Address City State ZIP <br /> 5444 Dry Creek Road Sacramento CA 95838 <br /> Phone Phone Email <br /> 626-627-8316 916-991-1100 mthomas@cgrs.com <br /> 13 Billing Party ❑Facility Owner ❑Facility Contact -T❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> same <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor [D—Architect <br /> First Name Last name If contractor,indicate type and license nu ^I �/�'1r T <br /> Address City State ZIP VFW <br /> � �9 <br /> s ?4 <br /> Phone Phone Email HEq�V/R0 �N C <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or projeci,x I <br /> �NTy <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 Nr <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. <br /> APPLICANT'S SIGNATURE: //G91'lLCLQ. DATE: 8-7-2024 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER 12 OTHER AUTHORIZED AGENT Compliance Services Manager-CGRS <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 /> Acc94Fdgy AssignedTo VN �fi ��A�` �// Linked FA ID ����,0 <br /> Dat� � ' �� PEn��(1 Fe vt W,W, { Record Number <br /> SRa40©4mm <br /> ❑Cash ❑Check# U '� s/ Confirmation# /�j / �/� Payment <br /> ./��L fpy cam/ l / l Received By <br /> Rev 07/10/2024 � �L I sil 174 <br />