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San Joaquin County Environmental Health Department Application Form Repairs or Remodel X Other□ Consultation □ Change of Owner License Plate Number □ Billing Party □ Facility Owner □ Facility Contact □ Contractor □ Architect JX1 Billing Party Facility Owner □ Property Owner□ Facility Contact □ Contractor □ Architect First Name Last name If contractor, indicate type and license numberThomasSusan Address Phone Email ^Architect□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor If contractor, indicate type and license numberFirst Name Last name RhodesDavid EmailPhone □ Contractor □ Architect□ Facility Contact □ Property Owner□ Billing Party □ Facility Owner If contractor, indicate type and license numberLast nameFirst Name State ZIPCityAddress EmailPhonePhone DATE: 06/1V2024 ty/ROPERTY / BUSINESS OWNER □ OPERATOR/MANAGER Linked FA IDAssigned ToAccepted By Fee If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO 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.______________________________________________________ If mobile food truck or pumper truck Contact Types required X Application for Operating Permit 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 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, Standards, STATE and FEDERAL laws. Acting as Agent for Chuze Fitness APPLICANT'S SIGNATURE: - Susan Thomas yCity Stockton State CA State CA City San Diego susan.thomas@chuzefitness.com City ______Newport Beach lhiga@acs-architects.com •77-5 - 1011 Camino Del Rio S, Suite 350 Phone 718 W Hammer Ln Supervisor DistrictAPN 8102014 Type of Service Requested Comments Tl remodel of an existing Toys-R-Us to a fitness gym VIN Record Number ZIP 92108 ZIP 92663 Address 101 Shipyard Way, Suite B (714) 436-9000 x1540 State CA Date . Tn. <- o PE IfcOf □ Property Owner □ OTHER AUTHORIZED AGENT Director of Architectural Services Title ’1 ia 95210 Facility Name _______Chuze Fitness Site Address