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❑ New Facility )M Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> 7-Eleven 32190 <br /> Site Address City State ZIP <br /> 4943 S Hwy 99 Stockton CA 95215 <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑ Consultation ❑ Change of Owner OM Repairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> I T <br /> Contact Types ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑Architect <br /> required <br /> AB filling Party ❑ Facility Owner ❑ Facility Contact roperty Owner actor ElArchitect <br /> ❑ P <br /> S <br /> First Name Christina Last name Tran If contrecto indicate type and license number <br /> Able Maintenance, Inc 312844, BAC10 HAZ <br /> Address city State ZIP <br /> 3224 Regional Parkway Santa Rosa CA 95403 <br /> Phone Phone Email <br /> 408-213-6039 <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 Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑Contractor ❑ Architect <br /> — .......... -... <br /> — -- _........ <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 /> I also certify that I have prepared this applicallonand that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. f p <br /> APPLICANT'S SIGNATURE: (_. ��� DATE: ' Z� + • 4 <br /> ❑ PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER MOTHER AUTHORIZED AGENT Project and Permit Coordinator REC ��cNT <br /> Title CD <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required q1� <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable, I,the owner or operator of the property located at the above site address, hereb�thorizt tho 2025 <br /> release of any and all results,geotechnical data and/or environmental/site assessment Information to the SAN JOAQUIN COUNTY ENVIRONMEMQ F��TH <br /> DEPARTMENT as soon as it Is available and at the same time it is provided to me or my representative. `C q <br /> C <br /> Accepted Assigne T Linked FA ID CEP OONr� <br /> C �I'7fl 007 5 8 q rMF�t <br /> Date PE Fee s Rec rd Number <br /> 2J ® � �l (Q 51Cp� 2F,0Tg0l <br /> ❑ Cash ❑ Check# Payment <br /> Confirmation# �/f— (ilj Received By <br /> Rev 07/10/2024 <br />