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State CA ziP 95207 <br />Billing Party Contact Types <br />required <br />Facility Owner XFacility Contact 0 Property Owner 0 Contractor 0 Architect <br />Facility Name 7 Eleven 41341A <br />Site Address 4415 Pacific Ave City Stockton <br />APN Supervisor District <br />11 0A0 -13 <br />Type of Service <br />Requested <br />o Application for <br />Operating Permit <br />0 Consultation RChange of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />If contractor, indicate type and license number First Name <br />Fateh7, LLC. <br />Last name <br />0 Billing Party Facility Owner X Facility Contact <br />1 <br />0 Property Owner 0 Contractor 0 Architect <br />Address 686 Shanghai Bend Rd <br />Phone Phone <br />(929) 393-6091 <br />[ <br /> <br />City Yuba City <br />Email <br />Sabisingh11418@gmail.com <br />State CA <br /> ZIP 95991 <br />San Joaquin County Environmental Health Department <br />Application Form <br />XBilling Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 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 <br />972-828-0711 <br />Phone Email <br />gm-elecrenewals@7-11.com <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name If contractor, indicate type and licen <br />Address City State ZIP <br />400 <br />Phone I Phone <br />1 <br />—I Email ail N 0 1 <br />. <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identicPieSdfl 0. <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site <br />form. <br />4 <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: a 4/;1)-2- `A <br />0 PROPERTY / BUSINESS OWNER x OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT Managing Member, Fateh7, LL <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 114 00036a3 <br />Datel j 31 1 PE 0 Fee __,... Em--, 3 <br /> • ....0 5 <br />Record Number <br />-d L 1 .35 0 <br />-1)& 172. op I 25 SSe. 5/67 i SS 71 els-ip <br />Nokopt-1615