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San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name 7 Eleven 17647E <br />Site Address State <br />CA <br />APN <br />Change of Owner Consultation Repairs or Remodel Other <br />None <br />License Plate Number VINNone <br />X) Property Owner^Billing Party Facility Owner Contractor^Facility Contact Architect <br /> Billing Party Facility Owner Facility Contact Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name Last nameSandeep Kaur <br />Address City State ZIP632 Tahoe St Manteca CA 95337 <br />Phone <br /> Property Owner Contractor Architect Facility Owner Facility Contact(^Billing Party <br />If contractor, indicate type and license numberLast nameFirst Name 7 Eleven Inc <br />City State ZIPAddress <br />Dallas TX 75313 <br />JxJ Property Owner Contractor Architect Facility Contact Facility Owner Billing Party <br />If contractor, indicate type and license numberLast name <br />City State ZIPAddressTXIrving <br />DATE: <br /> OTHER AUTHORIZED AGENT ^PROPERTY / BUSINESS OWNER OPERATOR/MANAGER <br />Title <br />Linked FA IDAssigned To <br />Fee <br />If mobile food truck or <br />pumper truck <br />Contact Types <br />required <br />[^Application for <br />Operating Permit <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 />Email <br />yessandeepl 5(<g)gmail.com <br />Email <br />gm-elecrenew als@7-11 .com <br />Email <br />qm-elecrenewals@7-11 .com <br />Phone <br />209-450-3369 <br />Phone <br />972-828-6889 <br />Phone <br />972-828-0711 <br />fey: <f~- <br />d iso <br />Type of Service <br />Requested <br />Comments ; <br />3200 Hackberry Rd <br />Phone <br />1048 W Yosemite Ave <br />Supervisor District <br />PO Box 139044 <br />Phone <br />Record Number <br />3^250)^^^ <br />ZIP <br />95337 <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site project <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business identified otit^s , <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 <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE:DATE: ---------------------------------------------------- <br />75^3^ <br />■D <br />City <br />Manteca <br />Date . . <br />First Name <br />7 Eleven Inc <br />Accepted By <br />_______________________ <br />PE |U>02-