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San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name 7 Eleven 41341 A <br /> Site Address 4415 Pacific Ave city Stockton State CA ZIP 95207 <br /> APN Supervisor District <br /> I L�•��10-I.3 _ 2- <br /> Type of Service D 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 VIN <br /> pumper truck <br /> Contact Types Billing Party Facility Owner XFacifityContact ❑Property Owner ❑Contractor ❑Architect <br /> Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name 7 Eleven Inc Last name If contractor,indicate type and license number <br /> Address PO Box 139044 City Dallas State TX ZIP 75313 <br /> Phone Phone Email <br /> 972-828-0711 gm-elecrenewals@7- <br /> 1 l.com <br /> ❑Billing Party J--*6ality Owner Facility Contact ❑Property Owner ❑Contractor 1-b Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Fateh7,_LLC. <br /> Address ZIP <br /> 686 Shanghai Bend Rd city Yuba City state CA ! 95991 <br /> Phone Phone 1 Email <br /> (929) 393-60911 Sabisin h1141 mail com <br /> ---�-- — 9_ °�9 —'--- —---- - -- ----- - <br /> ❑Billing Party ❑Facility Owner D Facility Contact ❑Property Owner ❑Contractor D Architect <br /> First Name Last name I If contractor,indicate type and licen� <br /> , Nr <br /> Address City State ZIP O <br /> Phone Phone Email ,q <br /> At <br /> 0 _. <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site T <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identif,. dA�lf� 4 1 Y <br /> form. FH <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. <br /> APPLICANT'S SIGNATURE: DATE: b <br /> D PROPERTY/BUSINESS OWNER OPERATOR/MANAGER []OTHER AUTHORIZED AGENT Mana Inn Member, Fateh7, LL . <br /> —3.�--- <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 /> Accepted B Assigned T Linked FA ID rA 000 8 03 <br /> Date PE Fee Record Nu er <br /> 3 i -- 2 !-- s )y�31 - - -- <br /> ��Q, 172. 6�D - $SSA5167 <br /> 195 71 g51b <br />