Laserfiche WebLink
❑ New F�ac�illiit�y �f X'Etxisting Facility <br /> /L S� U <br /> San Joaquin County Environmental Health Department <br /> _ Application Form <br /> Facility Name ` <br /> A Gas-Food Mart <br /> Site Address City ^4 State I ZIP <br /> 2115 W Yosemite Manteca CA 95337 <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑ Consultatlon ❑ Change of Owner u ❑ Repairs or Remodel ❑ Other <br /> Requested Operating Permit xxx <br /> Comments <br /> If mobile food truck or License Plate Number VIN ~� <br /> pumper truck <br /> Contact Types L7 Billing Party ❑ Facility Owner ❑ Facility Contact I ❑Property Owner 1 ❑ Contractor ❑ Architect <br /> required <br /> illing Party I ❑ Facility Owner ❑ Facility Contact ❑ Property Owner CepYrxto�;rKtoll❑ Architect <br /> Xxxx <br /> First Name Christina Last name Tran If contract , Indicate type and license number <br /> Able Maintenance Inc _ 312844• B A C10 HAZ <br /> Address City State ZIP <br /> 3224 Re Tonal Parkway Santa Rosa Ca 95403 <br /> Phone Phone Email <br /> 408-213-6039 christinat ivservicestation stems.com <br /> ❑ Billing Party Ix Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name // Last name If contractor, indicate type and license number <br /> Address Cityv State ZIP <br /> Phone Phone Email <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Ardy�ect <br /> First Name Last name If contractor, Indicate type and I N <br /> Address City State ZIP <br /> Phone Phone Email A <br /> S. N <br /> ��A <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that al i 10j*, cC y <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified o Ixl'�JEN <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 I <br /> APPLICANT'S SIGNATURE: / ,'j 2 DATE: _ <br /> ❑ PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER -40THER AUTHORIZED AGENT cli� <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, 1,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 /> L.DEPARTMENT as soon as it is available and at the same time It is provided to me or my representative. <br /> Accepted By Assigird To Linked FA ID <br /> l�'(lfi t'd " ail `7 71 <br /> Da PE Fee Record Number <br /> d2w2C� � �Ra5m095 <br /> 19 /� Payment <br /> � <br /> ❑ Cash ❑ Check# Confirmation# (p Received 8y <br /> Rev 07/10/2024 <br />