COMPLIANCE INFO_2026 - Laserfiche WebLink

Home Browse Search

❑ New Facility San Joaquin County Environmental Health Department Application Form Existing Facility (needs SR#) Facility Name Poppy Markets Site Address 713 N El Dorado St Stockton StattA zIP 95201 APN Supervisor District j If contractor, indicate type and license number Address 79First v_ Type of Service _^� ❑ Application for ❑ Consultation ❑ Change of owner [ t pairs or Remodel ❑ Other Requested Operating Permit Last name If contractd, indicate type and license number Christina Tran 485184 BC61/D40 HAZ Address City State ZIP 680 Quinn Ave Comments If mobile food truck or License Plate Number VIN Email pumper truck 408-213-6039 Contact Types required filling Party El Facility Owner 11 Facility Contact 11 Property Owner Contractor 11 Architect 61 Billing Party I ❑Facility Owrier � ®Facility Contact I ❑Property Owner ®Contractor ®Requester Last name ❑ Billing Party ❑ Facility Owner 11 Facility Contact ❑Property Owner El Contractor First Name Last name If contractor, indicate type and license number Address 79First State ZIP Phone Phone Email Name Last name If contractd, indicate type and license number Christina Tran 485184 BC61/D40 HAZ Address City State ZIP 680 Quinn Ave San Jose CA 95112 Phone Phone Email 408-213-6039 christina.tran@ crvicestationsysteJ is.com ❑Billing Party ❑Facility Owner ❑Facility Contact 13 Property Owner ❑Contractor ❑Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email ❑ Cash 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 cert ify that I have prepared this APPLICANT'S SIGNATURE: that the work to be performed will be done in accordance with all SAN IOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. 2/6/2026 DATE: ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR /MANAGER ❑OTHER AUTHORIZED AGENT Permit and Project Coordinator Title If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION 70 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. Accepted By Assigned To Linked FA ID 'TGT t° 12i ve_7A11 go . Kg Kyl ' Sal e kpl FAOm 14 Cc 18 Rev 07/10/2024 2 of ❑Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email ❑ Cash 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 cert ify that I have prepared this APPLICANT'S SIGNATURE: that the work to be performed will be done in accordance with all SAN IOAQUIN COUNTY Ordinance Codes, Standards, STATE and FEDERAL laws. 2/6/2026 DATE: ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR /MANAGER ❑OTHER AUTHORIZED AGENT Permit and Project Coordinator Title If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION 70 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. Accepted By Assigned To Linked FA ID 'TGT t° 12i ve_7A11 go . Kg Kyl ' Sal e kpl FAOm 14 Cc 18 Rev 07/10/2024 2 of Date PE UZ Fee a; Record Number Ff� ,l�_r t ❑ Cash ❑ Check # ❑ Confirmation # Payment Received By