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❑ New Fatuity W� Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name MOE'S STOP AND SHOP MARKET N LIQUOR <br /> Site Address City State ZIP <br /> 1628 HARBOR ST STOCKTON CA 95203 <br /> APN Supervisor District <br /> Type of Service 2 Application for 0 Consuitatlon ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party 0 Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> ABDELRAHMAN NASSER <br /> Address City State ZIP <br /> 1628 HARBOR ST STOCKTON CA 95203 <br /> Phone Phone Email <br /> 209-9445523 <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name if contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑A � <br /> First Name Last name If contractor,Indicate type an 0,1 <br /> Address City State Z f O ��// <br /> 1 <br /> Phone Phone Email M„RO(f/ pQU <br /> N �■�I N k IV <br /> ry <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledge that all site and/or r <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 wit all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑DTHER AUTHORIZED AGENT <br /> Title <br /> If APPLICANT is not the BILLING PARTY,proof of authorization to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,1,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 To Linked FA ID <br /> 5 ev jl� C . L &+C' C Nam 1-4 31 <br /> D to PE Fee Rernrd Number <br /> ` f Payment <br /> ❑Cash ❑Check q Confirmation+4 1 t/P Received By <br /> Rev 07/10/2024 <br /> 01'1,001� (� <br />