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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 ZIP <br /> CA <br /> 1320 W Weber Avenue 1105203 <br /> APN Supervisor District <br /> 145-190-22 <br /> Type of Service lication for onsultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Opera i g Permit <br /> Comments <br /> Application for Workplan Review f-'r 5✓ c IiM✓k `L)-) <br /> If mobile food truck orate 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 Email <br /> 415-967-6040 siegel@rouxinc.co <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 ZI P <br /> 555 12th Street Oakland CA 94607 <br /> Phone Phone Email <br /> 415-967-6040 siegel@rouxinc.cori <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 0 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 O ( 1 <br /> Date � �� PE l v� Fee �:� Record NN-;a U O 19,35 <br /> ❑Cash ❑Check# Pleonfirmation# i ( t)��� Payment <br /> Received By <br /> Rev 07/10/2024 <br />