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Appatigg9�,yt1: ed When Submitted Properly Completed. B o Sign The Application. <br /> 1 �C APPLICATION <br /> ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> ENGINEER'S AND/ORIF VEHICLE INVOLVED, GIVE <br /> APPLICANT'S AND/OR o 4990 FOOD ESTABLISHMENTS,HOUSING Make _ <br /> CONTRACTOR AND/OR PUBLIC POOLS,WATER SAMPLING --- - <br /> BROKER AND/OR REAL ESTATE INSPECTIONS Lic. No <br /> IrENSE AND/OR :ENVIRONMENTAL' HEALTPOULTRY RANCHES AND KENNELS <br /> 3TRATION MISCELLANEOUS SERVICES Reg ist. No. - <br /> BER -- --_.___ PERMITISERVICES <br /> Color --__ - <br /> i Application Date V�-R 0__—__ Business/Name To Appear On Permit ARCO_ Petroleum Products CO. <br /> ,,Type Permit/Service Requested: Gasoline line test and repair <br /> Applicant Name _ ARCO Petroleum Products CO._ Address 6100 N. Hwy 99, Stockton, CA __91= <br /> U <br /> — Business Telephone No.209-931-5976Emergency Telephone No. 916-372-2755 <br /> a Property Location/Address <br /> -_'j Property Owner ARCO Petroleum Products CO_ Address 6100 N. Hwy 99, Stockton, CA 95205 <br /> Operator's Name Mercedes Acosta - _ - Address 6100 N. Hwy 99, Stockton, CA 95= <br /> 1. FOOD ESTABLISHMENTS Total Building Sq. Footage Restaurant, Maximum Seating Capacity <br /> ❑ RESTAURANT ❑ FOOD MARKET RETAIL ❑ FOOD MARKET WHOLESALE ❑ MEAT MARKET <br /> ❑ FOOD PROCESSING PLANT ❑ COMMISSARY ❑ ICE PLANT ❑ BAKERY <br /> ❑ ROADSIDE FOOD STAND ❑ LIQUOR STORE ❑ BAR ❑ ITINERANT RESTAURANT <br /> ❑ CONFECTIONARY STORE ❑ FOOD SALVAGER ❑ FOOD DEMONSTRATION ❑ FOOD VENDOR <br /> ❑ VENDING MACHINES/No. of ❑ MOBILE FOOD PREP. UNIT ❑ VENDING VEHICLE <br /> ❑ FOOD CROP HARVESTING/No. of Field Employees _.-___ __ X ServiG I,�'t, ' <br /> ALL APPLICANTS: Total Employees Including Operators UrikriOWri <br /> 2. HOUSING <br /> ❑ HOTEL/MOTEL/No. of Units -__ ❑ CERTIFICATE OF OCCUPA Y JUN 0 8 19gp <br /> ❑ MOBILE HOME PARK/No. of Spaces <br /> 3. WATER QUALITY ❑ WATER SAMPLE (Bacterial) ❑ CHEMICAL ENVIRCNWENIAL HEALTH <br /> ❑ PUBLIC WATER SYSTEM ❑ SURFACE WATER SUPPLY 13 WATER HAULER PEWIT 1 SERVICE' <br /> NO. OF PUBLIC SERVED (Connections) <br /> 4. RECREATIONAL HEALTH ❑ SWIMMING POOL ❑ SPA ❑ WADING POOL ❑ NATURAL BATHING PLACE <br /> 5. VECTOR CONTROL ❑ POULTRY FARM/Maximum No. of Birds <br /> r :ENNEL/Runways -._- - -_ — /Animal Population No. - No.of Confining Cages <br /> Sewage Disposal Method <br /> Solid Waste Disposal Method __-- <br /> Wate � <br /> Supply Source _ _ Animal Waste Disposal Method <br /> 6. CONSULTATION FEE 347� — <br /> 7. PLAN CHECKING FEE <br /> 8. REAL ESTATE <br /> REQUEST: Water Well Inspection Sample C1 Title Company <br /> Sewage System Inspection Cl Address Tele. No. <br /> Escrow No. <br /> Seller _ _ _-- -.-___ Seller Address _- <br /> Telephone No.— ---- - - ---__- Seller Agent Name <br /> Service Request For Date - --- — --------- -- - -- <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> Ordinances, state laws. W.F. Lew l Co struction, Inc. as agent for ARCO <br /> APPLICANT'S SIGNATURE X ---.- - Title 4M%,�f"hs_ '" <br /> 7tilt 7'" ct0 <br /> FOR DEPARTMENT USE ONLY <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 31 <br /> REMIT <br /> BILLING REMITTANCE $BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED <br /> AMOUNT <br /> FEE <br /> LESS <br /> PRORATION <br /> PLUS <br /> PENALTY or <br /> /� �j �f _ <br /> OTHER (j!�� , �' r / /DPz' Z. <br /> OTHER <br /> Received by Date I t No. Permit No. ISSu;I ite Mailed Delivered <br /> APPLICANT—RETURN ALL COPIES TO: ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON AVE.,P.O. -:ox 2009 STOCKTON,CA 95201 -- <br />