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❑ New Facility Existing Facility <br /> (needs SR##) <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Teichert 4 <br /> Site Address City State ZIP <br /> 120 Frank W Circle Ca 95206 <br /> Stockton <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑ Consultation ❑ Change of Owner ❑ Repairs or Remodel ❑ Other <br /> Requested Operating Permit XXX <br /> Comments <br /> If mobile food truck or License Plate Number 7pumper truck <br /> Contact Types Ul Billing Party ❑ Facility Owner IN Facility Contact ❑ Property Owner ® contractor ® Requester <br /> required XXX XXX <br /> Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner Contractor <br /> XXX e t,+/} <br /> First Name Last name If contractor, indicate type and licen a number <br /> Christina Tran 485184 B C61/D40 HAZ <br /> Address City State ZIP <br /> 680 Quinn Ave San Jose CA <br /> 95112 <br /> Phone Phone Email <br /> 408-213-6039 christinatpi,services ationsystems.cc <br /> ❑ Billing Party ❑ Facility Owner OF cility Contact ❑ Property Owner ❑ Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and li 1' <br /> Address City State ZIP <br /> Phone Phone Email — �- ?025 <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor H MENr <br /> pEp al. <br /> EA <br /> First Name Last name If contractor, indicate type and license num e <br /> Address city State ZIP <br /> Phone Phone Email <br /> I <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 a Mica 'on and that the work to be performed will be done In accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br /> Standards, STATE and FEDERAL �ws. <br /> APPLICANT'S SIGNATURE: DATE: <br /> ❑ PROPERTY BUSINESS OWNER ❑OPERATOR/MANAGER 1517DTHER AUTHORIZED AGENT Proiect and Permit Coordinator <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 tome or my representative. <br /> Accepted B _� � Assign Linked FA ID <br /> S�yy <br /> a 7 <br /> Date- I w 2� PE N Feeo.3-7 Record Number <br /> `� 40 V 15 4 a <br /> �� y� Payment <br /> ❑Cash ❑Check# Confirmation# 7 / Received By <br /> Rev 07/10/2024 2 of 6 <br />