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❑ New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name Podesto's BBQ <br /> Site Address 104 Lincoln Center city Stockton Star CA ZIP 95207 <br /> APN 09741011 5upervisorDistrlct <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number N/A VIN N/A <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact L3 Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact VfPropertyOwner ❑Contractor ❑Architect <br /> First Name Phil Lastnarne Johnson If contractor,indicate type and license number <br /> Address 374 Lincoln Center city Stockton state CA ZIP 95207 <br /> Phone Phone Email <br /> (209)478-9200 pjohnsonQsims-grupe.com <br /> ❑Blllirg Party ❑Facility Owner L3 Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name tf contractor,ind tate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑racility Contact ❑Property Owner ❑Contractor n Arc A Y41 <br /> E. <br /> First Name Lastrame If contractor,indicate type and �` _ <br /> Address City State z" OV 05 y <br /> Phone Phone Fina:l �AQl1/N co, <br /> BILLING ACKNOWLEDGEMENT:I,the undersi ned property or business owner for or authorized agent of same,acknowledge that all site a F <br /> specific ENVIRONMENTAL HEALTH DEPA T hourl charges assoc,a Kh this project or activity will be billed to me or my business as identltied on t i <br /> form. <br /> I also certify that i have prepared t ' app' i 7�rk to be performed will be done in accordance wit all AN JOAWIN Ordinance Codes, <br /> Standards,ST and FEDERAL I s. J<r� <br /> ;1P"81U0-C1P1E7R <br /> SIGNATURE: DATE:/BUSINESS O ER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT C—+� <br /> Title <br /> If APPLICANT Is not the B1 ING PARTY,proof of authorization to sign is required <br /> AUTHORIZATION TO RE E 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 ah results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENWRONMENTAL 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 <br /> Assigned To Lin A ID <br /> {sc� 3 ' 4�P-- A 000�' <br /> Date PIE 1 (0O 1 Fee 1r T N <br /> og <br /> J Payment <br /> ❑Cash CI <br /> Check A Confirmation u ? O g0.2- Received By <br /> Rev 07110/2024 b � i(� ] t45 e S ,,Q- o o�- i 1 <br /> / ?R' 01 (.p 0 22 <br />