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• ❑ New Facility ® Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name Favorite Cleaners <br /> Site Address 622 E Charter Way city Stockton State CA ZIP 95206 <br /> APN Supervisor District <br /> 167-150- 50 <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ®Other <br /> Requested Operating Permit <br /> Comments <br /> for 6 soil vapor boring wells •- t)T� L <br /> If mobile food truck or License Plate Number VIN <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 El Contractor ❑Architect <br /> First Name AECOM Tech Svs Inc. Last name Hamid If contractor,indicate type and license number <br /> Shapoor General contractor-64163 <br /> Address 2020 L St, Ste 400 clLcramento State CA ZIP 95811 <br /> Phone Phone Email <br /> 213-996-2630 ishapoor.hamld@aecom. com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact 75 <br /> Property Owner ❑Contractor ❑Architect <br /> First Name Joel Last name Sanchez If contractor,indicate type and license number <br /> Address 622 E Charter Way city Stockton State CA ZIP 95219 <br /> Phone Phone Email <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 /> 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 th^e.work�to- be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. 9/26/2025 <br /> APPLICANT'S SIGNATURE: DATE: <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT <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 ByAssigned To Linked FA ID� 'I L11) <br /> Date) -q ; PE ���� Fee v� Record Number <br /> a 5 015 <br /> C]Cash I` ❑Check# onfirmation# 2 W-1 02,D CA-4 Payment <br /> Received By <br /> Rev 07/10/2024 <br />