COMPLIANCE INFO_2025 - Laserfiche WebLink

Home Browse Search

O' Existing Facility□ New Facility San Joaquin County Environmental Health Department Application Form State ZIP 952422448 West Kettleman Lane CA APN Supervisor District E/Change of Owner□ Consultation □ Repairs or Remodel □ Other This store is transferring from franchisee to franchisee on 10/09/25 License Plate Number VIN □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect □ Billing Party □ Facility Contact □ Property Owner □ Contractor □ Architect If contractor. Indicate type and license numberLast name ^/Billing Party □ Property Owner □ Contractor □ Architect□ Facility Owner □ Facility Contact If contractor, indicate type and license numberLast nameFirst Name N/A7 Fleven 43171.A Address P.O. Box 139044 Phone )m □ Property Owner □ Contractor□ Facility Contact□ Billing Party □ Facility Owner First Name Last name City StateAddress EmailPhonePhone DATE; □ OPERATOR / MANAGER□ PROPERTY / BUSINESS OWNER Accepted By Vidal Pedraza AssignedTo Francisco Ruiz Date 10/7/25 179FeePE1602 □ Check tt□ Cash Rev 07/10/2024 If mobile food truck or pumper truck Contact Types required □ Application for Operating Permit Email electronicrenewals@71 l.c ZIP 75313 Payment Received By Phone (972) 803-0442 ZIP 95242 State CA Phone (209) 369-3124 Bp Confirmation « A K/Facility Owner Facility Name 7-Eleven 43171A Site Address Type of Service Requested Comments First Name Amrit Path Inc c/o Harman Bisla Address 2448 West Kettleman Lane Phone (972) 803-0442 •that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, Ruth Pardo, Firm Administrator of Solomon, Saltsman & □ OTHER AUTHORIZED AGENT Jamieson, on behalf of 7-Eleven Inc. Title Linked FA ID FAOXZXZXI) t=> Record Number S P.2. <5 QI 5 51 City Dallas City ________________Lodi ‘lectronic(enewals( i)7-11 com 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. State TX If contractor, indicate type and .L;r°cr %a BILUNG ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or pro?bLMEMr 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 aj Standards,STATE and FEDERMlaw^ APPLICANT'S SIGNATURE<^S— City Lodi