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□ Existing Facility <br />San Joaquin County Environmental Health Department <br />ApplicationForm <br />ZIP <br />95210 <br />Supervisor District <br />□ Other□ Repairs or Remodel□ Change of Owner□ Consultation <br />non-hazardous food items <br />VIN <br />□ Architect□ Contractor□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party <br />□ Architect□ Contractor□ Property Owner□ Facility Contact□ Billing Party <br />If contractor, indicate type and license numberLast name <br />ZIPState 94568CA <br />EmailPhone <br />□ Architect□ ContractorBilling Party □ Property Owner□ Facility Contact□ Facility Owner <br />If contractor, indicate type and license numberLast name <br />ZIPState 94568CA <br />Q Architect <br />Si kH puinriw f <br />□ Contractor□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party <br />Last nameFirst Name <br />StateCityAddress <br />EmailPhonePhone <br />DATE: 9/12/2025 <br />□ OPERATOR/MANAGER□ PROPERTY / BUSINESS OWNER <br />Assigned ToAccepted By <br />FeeDate, <br />□ Cash <br />Rev 07/10/2024 <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />□ Application for <br />i Operating Permit <br />Payment <br />Received By <br />Email <br />Licensing@ros.corT <br />City <br />Dublin <br />City <br />Stockton <br />City <br />Dublin <br />Phone <br />925-338-7277 <br />O' OTHER AUTHORIZED AGENT Business License Coordinator <br />Title <br />State <br />CA <br />^Confirmation It□ Check# <br />Facility Name <br />Ross Dress For Less #2760 <br />Site Address <br />730 W. Hammer Lane <br />APN <br />First Name <br />Ross Dress For Less, Inc. <br />Address <br />5130 Hacienda Dr <br />Phone <br />First Name <br />Ross Dress For Less #2760 <br />Address <br />5130 Hacienda Dr # B3N6 <br />Phone <br />925-965-4400 <br />If contractor, indicate typj^kg^j^ <br />w 1 <br />^Facility Owner <br />202S— <br />I • J L. Ml <br />b'n'thls'F <br />New Facility <br />Linked FA ,0^ <br />RecorcLNumber <br />&Q250>He>2-_______r <br />on behalf of Ross Dress for Less, Inc. <br />L™—N0™nZ¥M^oL°XXSe0 U—S operator et the property .coated at the above site address, hereby aothorUe the <br />rebase of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL H <br />DEPARTMENTas soon as it is available and at the same time it is provided to me or my representative. <br />Type of Service <br />RequestecHealth Inspectio <br />Comments , „ n , <br />Retail Clothing Store: Selling Family Clothing, Accessories,Home Accent, & less than 141 sq ft of prepackaged <br />License Plate Number <br />BILLING ACKNOWLEDGEMENT: I. the imderslBned property or business owner, oporator o, authorized agent of same, acknowledge that'all <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as <br />!To certify that I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQU.N COUNTY Ordinance Codes, <br />Standards, STATE and FEDEI <br />APPLICANT'S SIGNATURE!^