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❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name 1320 W Weber Avenue <br /> Site Address City Stockton State CA ZIP <br /> 1320 W Weber Avenue 105203 <br /> APN Supervisor District <br /> 145-190-22 <br /> Type of Service lication for onsultation El Change of Owner El Repairs or Remodel ❑ Other <br /> Requested OM era Permit <br /> Comments <br /> Application for Workplan Review i%L"L✓� �=' V11 <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types 0 Billing Party ❑ Facility Owner ❑ Facility Contact 0 Property Owner 0 Contractor ❑ Architect <br /> required <br /> 0 Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> Emily Siegel <br /> Address City State ZIP <br /> 555 12th Street, Suite 250 Oakland CA 94607 <br /> Phone Phone 4iegel@rouxinc.cot,n <br /> mail <br /> 415-967-6040 <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner 0 Contractor ❑ Architect <br /> Roux <br /> First Name Last name If contractor, indicate type and license number <br /> Emily Siegel A HAZ 964122 <br /> Address City State ZIP <br /> 555 12th Street Oakland CA 94607 <br /> Phone Phone Pegel@rouxinc.conq <br /> mail <br /> 415-967-6040 <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact 0 Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> Andy Gabriel <br /> Address City State ZIP <br /> 1320 W Weber Avenue Stockton CA 95203 <br /> Phone Phone Email <br /> 410-371-6934 andy@coldtrack.co <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 nd 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: 1/23/2026 <br /> ❑ PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ® OTHER AUTHORIZED AGENT Roux Associates, Inc. <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 Assigned, Linked FA ID <br /> Date f f � PE ©� Fee � • V: Record Nber <br /> 9P-;t(x0 <br /> f ?35 <br /> ❑ Cash ❑ Check# [ bnfrmation# 1 ='� �"� > Payment <br /> Received By <br /> Rev 07/10/2024 <br />