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❑ New Facility X Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Kwik Sery Boyett Petroleum #98 <br /> Site Address City State ZIP <br /> 2501 Jackson Ave Escalon CA 95320 <br /> APN Supervisor District <br /> A21. 7 - ► � f <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner rI Repairs or Remodel ❑ M C�T <br /> Requested Operating Permit C <br /> Comments <br /> E8 + 0 <br /> If mobile food truck or License Plate Number VIN 2�24 <br /> pumper truck S <br /> JN ^ A <br /> Contact Types ❑ Billing Party El Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor(JEA� �ITQ� <br /> required �R�EPARTI�jE <br /> llling Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner Xcontractor F5-Archit ect <br /> First Name Last name If contractor, indicate type and license number <br /> CGRS, Inc Matt Thomas A/HAZ 803616 <br /> Address City State ZIP <br /> 5444 Dry Creek Road Sacramento CA 95838 <br /> Phone Phone Email <br /> 626-627-8316 916-991-1100 mthomas@cgrs.com <br /> E3 Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license number <br /> same <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type and license nu '1 rA�7, C� <br /> Address City State ZIP VFW <br /> G <br /> Phone Phone Email SA <br /> ON c <br /> IA17-y <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project Nr <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 I have prepared this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards, STATE and FEDERAL laws. / <br /> APPLICANT'S SIGNATURE: e4&7 /1�.9otadi DATE: 8-7-2024 <br /> ❑ PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER ER OTHER AUTHORIZED AGENT Compliance Services Manager-CGRS <br /> Title <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 /> Acc949d By AssignedTo Linked FA ID <br /> '1c Bloc�a A 0(D3910 <br /> Dat� : PEn �(1 Fe i� Record NumberSRa ` 0©400 <br /> ❑ Cash ❑ Check# V + s/ Confirmation# 1 l �l� ReceivPaymed <br /> f�-y Received By <br /> Rev07/10/2024 `"' 4 -4 l�sL l 17�o l 1 1 <br /> 6L p-e,rni[+ PMti T:1� <br />