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❑ New Facility Existing Facility <br /> Iv ads- S'9* <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Xpress Gas & Mart Inc <br /> Site Address City State ZIP <br /> 3440 E Main St. Stockton CA 95208 <br /> APN Supervisor District <br /> 15-7- I (PQ-0 <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner 8 Repairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> Comments <br /> See Enclosed <br /> VIN <br /> If mobile food truck or License Plate Number <br /> pumper truck <br /> Contact Types ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> required <br /> Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner It ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> Cindy Cadacio-Chan 958763 A <br /> Address City State ZIP <br /> 3100 Oak Rd., Suite 205 Walnut Creek CA 94597 <br /> Phone Phone Email <br /> 925-499-6294 permits@ecochek.com <br /> ❑ Billing Party Facility Owner Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> Zia Omar <br /> Address City State ZIP <br /> 3440 E Main St. Stockton CA 95208 <br /> Phone Phone Email <br /> 510-378-2992 xpressfuel3@gmail.com <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor A i T <br /> First Name Last name If contractor, indicate type and livens <br /> Address City State SAN" ZIP 6 <br /> Q <br /> Phone Phone Email Ff H NTy M p N� NrAL <br /> JDA <br /> ft <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 work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards, STATE and FEDERAL la� <br /> APPLICANT'S SIGNATURE: -- DATE: 3/27/2026 <br /> ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ® OTHER AUTHORIZED AGENT Office Business/Affaim 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 /> S-s-a cp 'ai'bl PreSf-v FA000Gy23 <br /> Date 3 '-3V)20 PE�+ Fee 0 ,5 3-7 970 Record Number5� 9202 <br /> /1Q^ <br /> 26�l 7 <br /> ❑ Cash ❑ Check# Payment <br /> — Y— cV9 <br /> Confirmation # Received By <br /> Rev 07/10/2024 <br />