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0 New Facility 12 Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name 3314 North Delaware Ave <br /> Site Address City State ZIP <br /> 3314 North Delaware Ave Stockton CA 95204 <br /> APN Supervisor District <br /> 111-110420 <br /> Type of Service ❑Application for 0 Consultation ❑Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit Environmental <br /> Comments <br /> Environmental Assessment <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 0 Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Larry Solari <br /> Address Ci tockton State ZIP 95219-2364 <br /> 3247 West March Lane#200 CA <br /> Phone Phone Email <br /> 209.639.3763 Isolaricpa@gmaiI.com <br /> 0 Billing Party 0 Facility Owner ❑Facility Contact 0 Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Robbins Family LP <br /> Address city Stockton State CA ZIP 95207 <br /> 1044 Rivara Road#110A <br /> Phone Phone Email <br /> 209.639.3763 <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 /> 1 also certify that I have prepared t ' application and that the work to be performed will be done in accordance with al SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws.),. <br /> aws, <br /> APPLICANT'S SIGNATURE: DATE: <br /> ❑PROPERTY/BUSINESS OWNER IROPE /MANAGER ❑OTHER AUTHORIZED AGENT O, <br /> Ti <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 /> Date PE Fee Record Number <br /> J-�Payment <br /> ❑.Cash ❑Check# .13 Confirmation#. Received By <br /> Rev 07/10/2024 <br />