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Facility Name 7 Eleven 17647E <br />Site Address State <br />CA <br />APN <br />X Change of Owner Consultation Repairs or Remodel Other <br />None <br />License Plate Number VINNone <br />Property Owner^Billing Party ^Facility Owner Contractor^Facility Contact Architect <br /> Billing Party ^Facility Owner Facility Contact Property Owner Contractor Architect <br />First Name If contractor, Indicate type and license numberLast nameSandeep Kaur <br />Address City State ZIP632 Tahoe St Manteca CA 95337 <br />Phone -.4 <br />^Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last name <br />7 Eleven Inc <br />Address City State ZIP <br />Dallas TX 75313 <br />55 Property Owner Contractor Architect Facility Owner Facility Contact Billing Party <br />If contractor, indicate type and license numberLast name <br />City State ZIPAddressTX 75063Irving3200 Hackberry Rd <br />Phone <br />DATE: <br />^PROPERTY / BUSINESS OWNER OTHER AUTHORIZED AGENT OPERATOR / MANAGER <br />Title <br />Linked FA IDAssigned ToAccepted By <br />Fee <br />^â– Ollpl^ <br />San Joaquin County Environmental Health Department <br /> Application Form <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <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. <br />APPLICANT'S SIGNATURE: <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 />^(Application for <br />Operating Permit <br />Email <br />yessandeepl 5(jj)gmail.com <br />Email <br />gm-elecrenew$ls(g)7-11 .com <br />Email _ <br />gm-elecrenew als@7-11 .com <br />Phone <br />209-450-3369 <br />Phone <br />972-828-6889 <br />Phone <br />972-828-0711 <br />S.n0!. OD<2) <br />Type of Service <br />Requested <br />Comments i <br />1048 W Yosemite Ave <br />Supervisor District <br />PO Box 139044 <br />Phone <br />ZIP <br />95337 <br />PE <br />City <br />Manteca <br />Record Number <br />SR.2'5Q)HulfcDate . . <br />4/3/2 <br />First Name <br />7 Eleven Inc