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k □ New Facility ® Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name 610 Cherokee Petroleum Inc Site Address 610 S Cherokee Lane APN Supervisor District [^Change of Owner □ Repairs or Remodel □ Other□ Consultation License Plate Number VIN □(Property Owner □ Contractor □ Architect□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect□ Facility Owner □ Facility Contact□ Billing Party If contractor, indicate type and license numberFirst Name Last nameMohammad State ZIPAddress EmailPhone □ Architect□ Property Owner □ Contractor□ Facility Owner □ Facility Contact□ Billing Party If contractor, indicate type and license numberLast nameFirst Name State ZIPCityAddress EmailPhonePhone □ Architect□ Contractor□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party If contractor, indicate type and license numberLast nameFirst Name ZIPStateCityAddress EmailPhonePhone 05/22/2025DATE: □ OTHER AUTHORIZED AGENT □ OPERATOR / MANAGER[£ PROPERTY / BUSINESS OWNER Title Assigned To FeePEDate □ Check«□ Cash Rev 07/10/202'1 3SC Confirmation it Contact Types required If mobile food truck or pumper truck □ Application for Operating Permit Payment Received By Type of Service Requested Comments City Lodi Alzghoul 510 Myrtle Ave Ste 209 So San Francisco cA'^4080 I Phone ZIP 95240 Accepted By p 4 1 ^lilts' If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required 4 AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site^ddressfw/^ly authorize release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY wtyONMENTAT l^ALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative.q . ~ Record Number SIZ2&2) I /SO State CA BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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, Standards, STATE and FEDERAL A I'UHaL APPLICANT'S SIGNATURE: » r r r izr r #mi-