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❑ New Facility ® Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Quick-n-Save#1 <br /> Site Address 1901 S. El Dorado St city Stockton State CA ZIP 95206 <br /> APN 165-080-19 Supervisor District <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner ❑Repairs or Remodel ®Other <br /> Requested Operating Permit WP Review <br /> Comments <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 ❑Facility Contact ❑Property Owner IN Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> FREY Environmental A Haz 643673 <br /> Address 1336 Brommer St city Santa Cruz State CA ZIP 95062 <br /> Phone Phone Email <br /> 831/464-1634 408/859-6567 terrykinn@freyinc.com <br /> 13 Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Terrence Kinn Last name If contractor,indicate type and license number <br /> Address 1336 Brommer St City State ZIP <br /> Santa Cruz CA 95062 <br /> Phone Phone Email <br /> 408-859-6567 terrykinn@freyinc.com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Rajinder Last name Sharma If contractor,indicate type and license number <br /> Address 33215 Falcon Dr. City State CA ZIP <br /> Fremont 94555 <br /> Phone Phone Email <br /> 510-825-5251 2rajindersharma@gmail.c m <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 /> 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: - - DATE: 6/10/26 <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER _,[OTHER AUTHORIZED AGENT Project Manager <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 /> Accepted By / Assigned To Linked FA ID <br /> Date ( ;. � PE Fee Record Number!9' 1 ./] <br /> ❑cash t ❑Check q !-+E3 firmation q 222250602, 222193�8(09,9,1(/Paayment <br /> 222158389 Received By <br /> Rev 07/10/2024 <br />