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❑ New Facility X Existing Facility San Joaquin County Environmental Health Department Application Form Facility Name Kwik Sery Boyett Petroleum #98 Site Address City State ZIP 2501 Jackson Ave Escalon CA 95320 APNSupervisor District A21 7 - ► 5f Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner IR Repairs or Remodel ❑ M C � T Requested Operating Permit C Comments E8 + 0 P7 If mobile food truck or License Plate Number VIN224 pumper truck S Contact Types ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ZLyl required EPARTME llling Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner Xcontractor ❑ Architect First Name Last name If contractor, indicate type and license number CGRS , Inc Matt Thomas A/HAZ 803616 Address City State ZIP 5444 Dry Creek Road Sacramento CA 95838 Phone Phone Email 626 -627-8316 916 -991 - 1100 mthomas@cgrs. com E3 Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect First Name Last name If contractor, indicate type and license number same Address City State ZIP Phone Phone Email ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect First Name Last name If contractor, indicate type and license nuWd;eU Address City State ZIP VFX G 8AA19 ?� Phone Phone Email A�N c JQA17wy BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project Nr 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. �/ APPLICANT'S SIGNATURE : /�/ / /1.9otao4di DATE : 8-7-2024 ❑ PROPERTY / BUSINESS OWNER ❑ OPERATOR / MANAGER ER OTHER AUTHORIZED AGENT Compliance Services Manager - CGRS Title 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. Acc949d By Assigned. To Linked FA ID K& WItf BlocA 0 (D3910 Dat PE /) C) V Fe Reclord Number �S� f Ra ` 0 © 400 ❑ Cash Payment Received By Rev 07/10/2024 l0 (o �L 1 17 , l 5V ) d ( fat I wLt ` /rryi 9MtD)