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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> San Joaquin County General Services Bldg <br /> Site Address City State CA ZIP <br /> 826 North California Street and 517 East Flora Street Stockton 95202 <br /> APN 139-175-180-000 Supervisor District <br /> 139-175-120-000 <br /> Type of Service ❑Application for Consultation ❑Change of Owner ❑Repairs or Remodel ®Other <br /> Requested Operating Permit <br /> Comments <br /> tvcr�+- UAA, <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ®Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> M Billing Party ®Facility Owner ®Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Sarish Khan (Facility Manager) <br /> Address 44 North San Joaquin Street Suite 540 City State ZIP <br /> Stockton CA 95202 <br /> Phone Phone Email <br /> 209-468-0310 Sarish.Khan@sjgov.org <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 license number <br /> Address City State ZI P <br /> Phone Phone Email <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.,., / l� <br /> APPLICANT'S SIGNATURE: c DATE: 04/10/2025 <br /> ❑PROPERTY/BUSINESS OWNER ®OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <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 Linked FA ID � <br /> Dat PE Fee Record Number <br /> kt 7 5 s a501 <br /> ❑Cash ill Check# onormation# C C / Payment <br /> t Z l �� Ub Received By. <br /> Rev 07/10/2024 <br />