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□ New Facility □ Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name TRADER JOE'S STORE #269 <br />Supervisor DistrictAPN <br />□ Change of Owner Q Repairs or Remodel□ Consultation <br />License Plate Number VIN <br />EXFacility Contact □ Contractor□ Facility Owner □ Property Owner□ Billing Party <br />□ Property Owner □ Contractor □ Architect□ Billing Party (3 Facility Owner □ Facility Contact <br />If contractor, indicate type and license numberLast name <br />Phone Email <br />Scontractor □ Architect□ Facility Owner □ Facility Contact □ Property Owner□ Billing Party <br />Phone Email <br />[5Facility Contact □ Property Owner □ Contractor □ Architect□ Facility Owner□ Billing Party <br />If contractor, indicate type and license number <br />ZIP <br />94105 <br />10/31/2024DATE: <br />PERMIT EXPEDITOR□fOTHER AUTHORIZED AGENT□ OPERATOR / MANAGER□ PROPERTY / BUSINESS OWNER <br />Title <br />Linked FA ID <br />□ Cash □ Check ft <br />Rev 07/10/2024 <br />Payment <br />Received By <br />Contact Types <br />required <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 />If mobile food truck or <br />pumper truck <br />□ Application for <br />Operating Permit <br />ZIP <br />95304 <br />ZIP <br />91016 <br />ZIP <br />94549 <br />First Name <br />PETER <br />City <br />SAN FRANCISCO <br />State <br />CA <br />Site Address <br />2530 NAGLEE RD. <br />Phone <br />4153056661 <br />Email <br />LSOLIS@BURNH AMN ATIONWIDE.COM <br />Last name <br />SHADEK <br />Last name <br />SOLIS <br />City <br />TRACY <br />City <br />LAFAYETTE <br />State <br />CA <br />If contractor, indicate type and license number <br />919541 CLASS B <br />City <br />MONROVIA <br />Type of Service <br />Requested <br />Comments <br />First Name <br />LAURENCE <br />Address <br />535 MISSION STREET 14TH FLOOR <br />Phone <br />First Name <br />TRADER JOE’S COMPANY, INC <br />Address <br />800 SOUTH SHAMROCK AVE. <br />Phone <br />Address <br />3458 MT. DIABLO BLVD <br />Phone <br />Assigned To <br />□ QtfcfirCElygQ <br />% <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <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 laws. |_aurence Sq| jq <br />APPLICANT'S SIGNATURE: no,cm <br />MV 19 2024 <br />State <br />CA <br />Accepted By <br />_________iCva. ^3 c--*’ <br />Date iu/Record Number <br />Confirmation # <br />PE <br />I b 0 I