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❑ New Facility Existing Facility <br /> fV"S Sly" <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Elite Fuels <br /> Site Address City State ZIP <br /> 2375 N.Tracy Blvd. Tracy CA 95376 <br /> APN Supervisor District <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner IM Repairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> Comments <br /> See application for Scope of Work <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner Acontractor ❑ Architect <br /> required <br /> Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> Cindy Cadacio-Chan 958763 A <br /> Address City State ZIP <br /> P.O. Box 1394 Lafayette CA 94549 <br /> Phone Phone Email <br /> 925-499-6294 permits@ecochek.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 ❑ Ap� � <br /> First Name Last name If contractor, indicate type an /� E <br /> Address City State ZIPSED 1 <br /> 1�- 2025 <br /> Phone Phone Email EJOAQUIly SUN <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site an r BEN <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: _ DATE: 9/11/2025 <br /> ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER MOTHER AUTHORIZED AGENT office/euslness Affairs 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 to me or my representative. <br /> Accepted By Assigne To AQ)(DCP&L- 43 <br /> d FA ID <br /> Rm RN r,_o . �tDr► I Ca �e <br /> Date PE Fee Record Number <br /> q /2 25 23D �S �� 5Ra501487 <br /> ❑ Cash ❑ Check# Confirmation# �O Q G"7� / r� Payment <br /> U U l I J Received By <br /> Rev 07/10/2024 <br />