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❑ New Facility Existing Facility <br /> (needs SRN) <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Tiwana&Sons Inc.dba Parkwoods Gas&Food(Shell) <br /> Site Address city State ZIP <br /> 1612 W. Hammer Ln. Stockton Ca 95209 <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel $]Other <br /> Requested Operating Permit <br /> Comments <br /> Dispenser/Bravo Frame Installtion &Veeder-Root Cold start for ISD install <br /> If mobile food truck or License Plate Number VIN <br /> pumpertruck <br /> Contact Types ®Billing Party ❑Facility Owner ®Facility Contact ❑Property Owner J9"Contractor - ® Requester <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner Iffi Contractor ❑Architect <br /> First Name L3stR9ffifiard If contractor,indicate type and license number <br /> Carrie 1001331 A <br /> Address city State ZIP 95205 <br /> 2535 Wigwam Dr Stockton CA <br /> Phone Phone Email <br /> 209-461-6337 arse@eliteiv.com <br /> ❑Billing Parry ❑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 Parry ❑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 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 workto be performed will be done In accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL layr9 /j <br /> APPLICANT'S SIGNATURE: (�J/2�,(� /l"/Ll� DATE: 121512025 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER RI OTHER AUTHORIZED AGENT Office Manager <br /> Title <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 /> Accepted By Assigned To Linked FA ID <br /> Date PE Fee Record Number <br /> ❑Cash ❑Check ItO Confirmation If Received <br /> Received By <br /> Rev 07/10/2024 2 of 6 <br />