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❑ New Facility Existing Facility <br /> (needs SR#) <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> 7-Eleven <br /> Site Address City State ZIP <br /> 4943 S Hwy 99 Stockton CA 95215 <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑ Consultation ❑ Change of Owner ❑ 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 61 Billing Party ❑ Facility Owner IN Facility Contact ❑ Property Owner ® Contractor ® Requestor <br /> required XXX XXX <br /> Billing Party O Facility Owner ❑ Facility Contact ❑ Property Owner AContractor ❑Architect <br /> XXX _ <br /> First Name Last name If contractor, Mclicate type and license number <br /> Service Station Systems; Christina Tran 485184,B C61/D40 HAZ <br /> Address C ity State ZIP <br /> 680 Quinn Ave San Jose CA 95112 <br /> Phone work Phone cefl Email <br /> 408-213-6039 408-640-0249 christinat@servicestations� tems.com <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑Arc M C I <br /> First Name Last name If contractor, indicate type and II G D <br /> Address City State ZIPAUG 21 20 5 <br /> Phone Phone Email SAN JOAQUIN CO N1Y <br /> ENVI <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same,acknowledge that all site and or prole ENT <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 law 7 r� <br /> APPLICANT'S SIGNATURE: J DATE: ! (0 — LJ <br /> ❑ PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER THEIR AUTHORIZED AGENT Project and Permit Coordinator <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 /> Accepte Assigned Linked FA I <br /> 3` c c �2ive,�a , ce Pt A. <br /> 000 <br /> Date � _ PE Fee Record Number <br /> l� J" <br /> ���/���� Payment _ <br /> ❑Cash ❑ Check# Confirmation# Received ey <br /> Rev 07/10/2024 2 of 6 <br />