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❑ New Facility Mxisting Facility <br /> (needs SR#) <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Quik Stop Market 125 <br /> Site Address City State ZIP <br /> 1580 W Main St Ripon CA 95366 <br /> APN Supervisor District <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of owner M 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 0 Billing Party ❑ Facility Owner ® Facility Contact ❑ Property Owner IN Contractor M Requestor <br /> required <br /> Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner C ractor ❑ Architect <br /> Ke 4 <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 servi estations stems.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 ❑ Architect <br /> First Name Last name If contractor, indicate type 20nse <br /> Address City State ZIP CC <br /> SEP <br /> Phone Phone --[Email <br /> JOAQUIN <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, ackn owl edg I7,4fe1) <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identi ie ENr <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�'L�.�'6"w DATE: 08/25/25 <br /> ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/MANAGER Ir'tI. OTHER 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 to me or my representative. <br /> Acce ted B Assigned To Linked FA ID <br /> p �1�C IJL g k,n�Qa l ► 1 iA L) ,r� <br /> Date PE „ q ^ Fee d/; 2 Record Number <br /> ^ 5 0 1 4 5 0- <br /> YI L �J S R oC <br /> ❑ Cash ❑ Check# Confirmation # / p Payment <br /> �.,0760 6- 3 Received By <br /> Rev 07/10/2024 2 of 6 -2z7 6+4.2,1a;Z, <br />