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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 076 <br /> Site Address City State ZIP <br /> 1030 S Olive Ave Stockton CA 95215 <br /> APN Supervisor District <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner ® 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 R1 Billing Party ❑ Facility Owner IN Facility Contact ❑ Property Owner ® Contractor ® Requester <br /> required <br /> illing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner Contractor ❑ Architect <br /> e ccQ.ofibr^ <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' 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 and licens�yy�r�er <br /> Address City State ZIP 1 <br /> Phone Phone Email SEP 09 <br /> n <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all silt /�t .� <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this projector activity will be billed tome or my busineshe V <br /> form. CEP <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 Cod2* Nr <br /> Standards,STATE and FEDERAL laws. t_ / ,, `- - , <br /> APPLICANT'S SIGNATURE: St"t - CHIGT.!'Yi slw 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 to me or my representative. <br /> Accepted By ,nLcy Rj\ ,� Assig o f Linked FA IDINTa 4-711 OD' <br /> n/ Date PE^� F �� l• Record Number <br /> L S R <br /> ❑ Cash ❑ Check# Confirmation # '7 / �c Payment <br /> �-� / 6D5)74�' Received By <br /> Rev 07/10/2024 2 of 6 <br />