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Existing Facility□ New Facility San Joaquin County Environmental Health Department Application Form Facility Name MOE'S STOP AND SHOP MARKET N LIQUOR Supervisor District □ Consultation □ Change of Owner □ Repairs or Remodel □ Other License Plate Number VIN □ Architect□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect□ Property Owner □ Contractor□ Billing Party 0 Facility Owner □ Facility Contact If contractor, indicate type and license number Phone Email □ Contractor □ Architect□ Facility Contact □ Property Owner□ Billing Party □ Facility Owner If contractor, indicate type and license numberFirst Name Last name ZIPCityStateAddress EmailPhonePhone □ Contractor□ Property Owner□ Facility Owner □ Facility Contact□ Billing Party Last nameFirst Name StateCityAddress EmailPhonePhone DATE: □ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGER□ PROPERTY / BUSINESS OWNER Title PE ^^2/74.5□ Check «□ Cash Rev 07/10/2024 vk oi Contact Types required If mobile food truck or pumper truck If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site address, hereby authorize the release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. 0 Application for Operating Permit Payment Received By( ZIP 95203 ZIP 95203 City STOCKTON State CA Last name NASSER State CA City STOCKTON EI Confirmation U L..------------- Type of Service Requested Comments Accepted By jeVC C. Site Address 1628 HARBOR ST APN First Name ABDELRAHMAN Address 1628 HARBOR ST Phone 209-9445523 Linked FA ID Record Number 5U25 Assigned To Fee.iiu.ea if contractor, indicate type an H^Pn&Nty Sx /U 7——----------- BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or (Way specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identified on this form. 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, ~'AT^^.^RALIa"s' OATB.