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/V <br /> ❑ New Facility ® 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 Supervise lstrin <br /> 111-110.420 <br /> Type of Service ❑Application for 0 Consultation 17 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 /> ConlactTypas OBilling PaW C)l Facllity0wnar. ;� ❑Faullty Contact OPropeny Owner _ ❑Contractor O,Arcthect required... _ - .. . <br /> ❑Billing Party ElFacility Owner ®Facility Contact Cl Property Owner ❑Contractor ❑Archhect <br /> First Name last name If contractor,indicate type and license number <br /> Larry Solari <br /> Address tockton state ZIP95219-2364 <br /> cl <br /> 3247 West March Lane#200 CA <br /> Phone Phone Email �J <br /> 209.639.3763 Isolaricpatagmail.com \yJ <br /> ®(Ailing Parry ®Facility Owner ❑Facility Contact OProperty Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,Indicate type and license number <br /> Robbins Family LP <br /> Address City State ZIP <br /> 1044 Rivera Road #110A Stockton CA 95207 <br /> Phone Phone Email <br /> 209.639,3763 <br /> ❑Billing Party ❑Facility owner El Facility Contact 0Property Owner ❑Contractor ❑Archhect n <br /> First Name last name If contractor,Indicate type and license number <br /> Address city State ZIP <br /> Phone Phone Email <br /> BILUNG ACKNOWLEDGEMENT:1,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 l 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 /> APPUCANi'S SIGNATURE: DATE: <br /> O PROPERTY/BUSINESS OWNER DOPE t/MANAGER ❑OTHER AUTHORIZED AGENT <br /> Tr <br /> If APPLICANT is not the BILUNG PARTY,proof of authorization to sign Is required <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property touted 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" - Aw%nedT, '— - - .Unked Fq)D. .: <br /> _. �� 1 . <br /> Date J - PE R"rd Number <br /> ri.� bfZ z°1�3 Sc6 SR ;L 400 C�a4 <br /> _ , . ayment.; <br /> nrmatlonOCash O Check p ec&ed B yPR <br /> Rev 07/10/2OZ4 <br />