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□ New Facility ® Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name McDonald’s Site Address City State ZIP2505 West March Ln Stockton Ca 95207 APN Supervisor District □ Consultation □ Change of Owner 51 Repairs or Remodel □ Other VIN □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect XI Billing Party □ Facility Owner IX Facility Contact □ Property Owner □ Contractor □ Architect First Name Last name If contractor, indicate type and license numberTomPatla Address City State ZIP4502 Georgetown PI Stockton Ca 95207 Phone □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner First Name Last name Address City State Phone Phone Email 11/24/2025DATE: □ OPERATOR/MANAGER OTHER AUTHORIZED AGENT□ PROPERTY / BUSINESS OWNER Assigned ToAccepted By Lydia BakerVidal Pedraza PE FeeDate160111/24/25 537 CbPayment 212025441Rev 06/12/2024 If mobile food truck or pumper truck If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Contact Types required □ Application for Operating Permit BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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, Standards, STATE and FEDERAL laws. . Q in. APPLICANT’S SIGNATURE: tftFWQ Type of Service Requested Comments Removal of existing Walk-In Cooler/Freezer and replace w/new License Plate Number Const. Manager Title ^0^ ---- A r ' Email tomp@mcdgs.org2t)9.608.3822 □ Contractop^q Architect If contractor, indicft^k/pgfend license number tmDF7W17?3-