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❑ New Facility _�Existing Facility <br /> (needs SR#) <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> _c iuik Stoil <br /> Site Address City State Zip <br /> 1196 W Louise Ave Manteca CA 95336 <br /> APN`XIH I N.., Supervisor District <br /> Type of Service ✓✓h ❑Application for ❑'Co_nsultatio-n ❑ Change of Owner ❑ Repairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> Comments --� <br /> replace the drop tube OPW 71SO on 91 tank <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types 6c1 Billing Party ❑ Facility Owner IN Facility Contact ❑Property Owner ® contractor ® Requestor <br /> required <br /> Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner tractor ❑Architect <br /> JCX7C `' ^ <br /> First Name Last name If contract r,indicate <br /> Christina type and license number <br /> Tran 485184 B C61/D40 HAZ <br /> Address City State ZIP <br /> 680 Quinn Ave San lose. CA 95112 <br /> Phone Phone Email <br /> 408-213-6039 1 christina.tran@ ervicestations ste ns.com <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If Contractor,indicate type and Icense number <br /> Address city State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑Arc ' e �or <br /> First Name Last name If contractor,indicate type and license num D <br /> Address City State ZIP <br /> Phone Phone Email <br /> Eq►�IROM �0 Nn, <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or pro a Nry. <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 appiicatioi and that the work to be performed will be done In accordance with all SAN 10AQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. / 1 <br /> APPLICANT'S SIGNATURE: _� #� L L�� DATE: 12/9/2025 <br /> ❑ PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER MOTHER AUTHORIZED AGENT Permit/Project Coordinator <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required Title <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,geotechnicai data and/or environmental/site assessment Information to the SAN 10AQUIN COUNTY ENVIRONMENTAL HEALTH <br /> DEPARTMENT as soon as it Is available and at the same time It is provided tome or my representative. <br /> Accepted By Assigned To Linked FA ID <br /> TF1M FA0000� 84 <br /> Date <br /> Z 91 �j C Rec u ber <br /> 1-7 <br /> ❑Cash ❑Check# lVJ a� a/ Confirmation# J —7 c Payment <br /> oZ/aZ /ZI C3 Z Received By <br /> Rev 07/10/2024 2 of 6 <br />