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❑ New Facility Existing Facility <br /> Nei-zi4 <br /> San Joaquin County Environmental Health Department <br /> Application Fore <br /> Facility Name <br /> 7-Eleven #41342 <br /> Site Address ity State ZIP <br /> 5205 <br /> 1233 E. Dr. MILK Blvd. Stockton CA <br /> APN Supervisor District <br /> —T <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner ® Repairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> Comments <br /> Monitor cold start performed. <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types 0 Billing Party ® Facility Owner ❑ Facility Contact ❑ Property Owner 0 Contractor ❑ Architect <br /> required <br /> Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner Contractor ❑ Architect <br /> 7qeebu.�sfar <br /> First Name Last name If contractor, indicate type and license number <br /> Walton Engineering, Inc 617238 A, B, Haz <br /> Address City State ZIP <br /> P.O. Box 1025 West Sacramentq CA 95691 <br /> Phone Phone Email <br /> 916-373-1166 veronica.f@walton ngineering.com <br /> ❑ Billing Party acility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> 7-Eleven <br /> Address 6aYlaS stat�X z175221 <br /> P.O. Box 711 <br /> Phone Phone Email <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ter'■ -1ED <br /> First Name Last name If contractor, Indicate type aft nu dumber <br /> 6 2 <br /> Address City State Jl6AQV111V COU <br /> Phone Phone Email <br /> 7H DEPARTMENT <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 laws. /�� � �� <br /> APPLICANT'S SIGNATURE: [/ DATE: 06/04/25 <br /> ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/MANAGER 93 OTHER AUTHORIZED AGENT Contractor <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 /> Accept By A gned To Linked FA ID�^ <br /> � III <br /> Date qy/r5 P;�� Fe�r�i �/ Record Number 11 <br /> 63 <br /> Payment <br /> ❑ Cash ❑ Check# Confirmation# �cs O I Received By <br /> Rev 07/10/2024 Fa'wa're / 0 <br />