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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 124 <br /> Site Address City State ZIP <br /> 505 N Main St Manteca CA 95336 <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑ Consultation ❑ Change of Owner [R 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 R] Billing Party ❑ Facility Owner IN Facility Contact ❑ Property Owner IN Contractor M Requestor <br /> required <br /> filling Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner Contractor ❑ Architect <br /> Q u.Q..d <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 Email <br /> Phone <br /> 916-343-3857 ste haniec serdcestations stems.c m <br /> ❑ Billing Party ❑ Facility Owner ELaname <br /> lity Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First 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 r <br /> First Name Last name If contractor, indicate type and license nu <br /> Address City State ZIP <br /> JQ <br /> fflTy <br /> Phone Phone Email H ,1 p NMEHy, <br /> EPA <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project <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 /> t'iSr <br /> APPLICANT'S SIGNATURE: st"A�.>tda- (�'G��i^ fey 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 /> Accepte By Assign d To Linked FA ID <br /> i <br /> C Date fE <br /> Fee Record Number <br /> - ' 5R. 0. 5® 14 5 3 <br /> ❑ Cash heck#1 Confirmation N Payment <br /> za7 6z: zp,I)` Received By <br /> Rev 07/10/2024 2 of 6 a—����� 3T <br />