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San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name 7 Eleven 38616A <br />Site Address City StateStockton CA 95206 <br /> Consultation ^Change of Owner Repairs or Remodel Other <br />________L. <br />License Plate Number <br /> <br />VIN <br />J <br />J^Biiling Party iXfacility Owner ArchitectR Facility Contact Property Owner Contractor <br /> Facility Contact^Billing Party Facility Owner Property Owner Contractor Architect <br />If contractor, indicate type and license numberFirst Name last name7 Eleven Inc <br />Address City State ZIPPO Box 139044 Dallas TX 75313 <br />Phone <br />Facility Contact Billing Party Property Owner Contractor Architect <br />If contractor, indicate type and license numberLast name <br />City StateStockton CA 95206 <br />I <br /> Property Owner Contractor Facility Contact Facility Owner Billing Party <br />Last name <br />ZIPCityStateAddress <br />EmailPhone <br />y <br />DATE: <br /> OTHER AUTHORIZED AGENTOPERATOR / MANAGER PROPERTY / BUSINESS OWNER <br />Accepted Bt <br />Fee <br />5 <br />3339 Dayton Herzog Ln <br />Phone <br />I Phone <br />1 ZIP <br />I <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <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 ENVIRONMENTAt HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />> Email ___ <br />gm-elecrenewfils@7-11 .com <br />Phone <br />(650) 740-1718 <br />Phone <br />972-828-0711 <br />^Facility Owner <br />Email <br />sukhi_2222@yahoo.com <br />First Name <br />Somal and Sons, Inc <br />Address <br />Assigned J6 <br />—-n—• _rpe ox n ..... <br />72^ to*.!'# 1^52.55S& <br />I5S-7HIIC, <br />I ZIP <br />. n Architect <br />I J~A <br />If contractor, indicate type and lie ' <br />601 Carolyn Weston Blvd <br />Supervisor District <br />___L__ <br /> Application for <br />I Operating Permit <br />Linked FA ID ,fA 00^371. <br />Record Number <br />APN <br />Type of Service <br />Requested <br />Comments <br />rork to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />President, Somal and Sons Inc <br />Title <br />______________________________________________________________________ <br />BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/ar/pxj^ectM2. <br />specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity w.ll be billed to me or my business as identified on f <br />form. <br />I also certify that I have prepared this application and that thywork <br />Standards. STATE and FEDERAL laws. <^'[1 YC V( <br />APPLICANT'S SIGNATURE: _____ <br />First Name