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❑ New Facility XlExisting Facility <br /> (needs SR#) <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Quik Stop Market 152 <br /> Site Address City State ZIP <br /> 1721 S Cherokee Lane 1 Lodi CA 95240 <br /> APN Supervisor District <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner ® Repairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumpertruck <br /> Contact Types RI Billing Party ❑ Facility Owner IN Facility Contact ❑ Property Owner ® Contractor ® Requestor <br /> required <br /> Billing Party ❑ Facility Owner ❑ Facility Contact <br /> ❑ Property Owner Contractor ❑ Architect <br /> First Name Last name If contrac or, indicate type and license number <br /> Stephanie Charissa 485184 B, C61/D40, HAZ <br /> Address City State ZIP <br /> 3900 Commerce Drive West Sacramento CA 95691 <br /> Phone Phone Email <br /> 916-343-3857 ste haniec sere' estations stems.c m <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 :,Llity Contact ❑ Property Owner El Contractor ❑ Architect <br /> First Name me 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 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: sr<� (�f�f Rai"(S'SrR/ DATE: 08/25/25 <br /> ❑ PROPERTY/BUSINESS OWNER ❑ OPERATOR/MANAGER MOTHER AUTHORIZED AGENT Operations 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 tome or my representative. <br /> Accepted ;/� AssignedAToiLinked FA I_ <br /> c lL� <br /> Date PE Fe Record Number <br /> C� 5� 5 a 5 14 <br /> ❑ Cash ❑ check N Confirmation #1 a0`�/ �V'17 C Payment <br /> i �vc� u r1 Received By <br /> Rev 07/10/2024 2 of 6L— <br />