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❑ New Facility Existing Facility <br /> / \ (needs SR#) <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name Poppy Markets <br /> 95201 <br /> Site Address 713 N El Dorado St Stockton StattA zIP <br /> APN Supervisor District <br /> _^� l <br /> 1 �• <br /> Type of Service ❑Application for ❑ Consultation ❑ Change of Owner &Aepalrs or Remodel ❑ Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types 61 Boling Party I ❑ Facility Owner ® Facility Contact I El Property Owner ® Contractor I@ Requester <br /> required <br /> filling Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner Contractor ❑ Architect <br /> Ili <br /> —Firs t—Na me Last name If contractoY,indicate type and license number <br /> Christina Tran 485184 BC61/D40 HAZ <br /> Address City State ZIP <br /> 680 Quinn Ave San Jose CA 95112 <br /> Phone Phone Emall <br /> 408-213-6039 1 christina.tran@ crvicestationsv; is.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 /> Address City State ZIP <br /> Phone Phone Email <br /> El Billing Party El Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑Architect <br /> First Name Last name If contractor, indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <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 applicatio an that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. 2/6/2026 <br /> APPLICANT'S SIGNATURE: I , � "k�� DATE: <br /> ❑ PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑ OTHER AUTHORIZED AGENT Permit and Project Coordinator <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 /> YJa ey }21 vt-V A- Kg K V1,01 1190ekol FAOm 14 ro 18 <br /> Date PE Fee a; Record Number <br /> ❑ Cash ❑Check# ❑Confirmation# Payment <br /> Received By <br /> Rev 07/10/2024 2 of 6 <br />