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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 /> Quik Stop Market 121 <br /> Site Address City State ZIP <br /> 1196 W Louise Ave Manteca CA 95336 <br /> APN Supervisor District <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner B Repairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> I F <br /> Contact Types IXI Billing Party ❑ Facility Owner IN Facility Contact ❑ Property Owner M Contractor M Requestor <br /> required <br /> Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property OwnerAN—Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> Stephanie Charissa 485184 B, C61/D40, HAZ <br /> Address City State ZIP <br /> 3900 Commerce Drive West Sacramento CA 95691 <br /> Phone Phone Email <br /> 916-343-3857 ste haniec serv'cestationsystems.c m <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 ❑ A <br /> First Name Last name If contractor, indicate type an EVI r <br /> Address City State ZI F6EP 0'9 202, <br /> Phone Phone Email rJAQU/N <br /> NVIRO COlip <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site an o �. <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. <br /> APPLICANT'S SIGNATURE: s� C�7 GS-SGt� DATE: 08/25/25 <br /> ❑ PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER (MOTHER AUTHORIZED AGENT operations Manager <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 tome or my representative. <br /> Acce ed y n IZ/V� Assigne To d&k Linked FA ID 00 <br /> C <br /> 9// a A <br /> Date PE��®� Fee ���� Record Number <br /> Z SRM I 1 <br /> ❑ Cash ❑ Check#I onfirmation # �`� �b/ Received B <br /> 4 Y <br /> Rev 07/10/2024 2 of 6 eZ074,+/:>'b l g <br />