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□ New Facility S Existing Facility Application Form Facility Name Food Mart Kitchen Remodeling Site Address 5777 French Camp Road,City State ZIPStocktonCA Supervisor District □ Change of Owner ® Repairs or Remodel □ Other□ Consultation Remodeling of Kitchen area of 293.23 SOFT, in the existing food mart. License Plate Number VIN □ Billing Party □ Facility Owner □ Facility Contact K Property Owner □ Contractor □ Architect □ ContractorKI Billing Party □ Facility Owner □ Facility Contact El Property Owner □ Architect If contractor, indicate type and license numberFirst Name Last nameDarshan Singh Address 5777 French Camp Road, Phone □ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor M Architect If contractor, indicate type and license numberFirst Name Last nameJaspal Sidhu Address City State ZIPCA 95630Folsom1024 Iron Point Road Phone □ Facility Contact □ Property Owner □ Contractor □ Architect□ Billing Party □ Facility Owner If contractor, indicate type and license numberFirst Name Last name StateAddressCity ZIP Phone EmailPhone DATE: □ OTHER AUTHORIZED AGENT □ OPERATOR/MANAGEREX PROPERTY / BUSINESS OWNER Title □ Check tl &Rev 07/10/2024 If mobile food truck or pumper truck Contact Types required □ Application for Operating Permit San Joaquin County Environmental Health Department Email 76express@sbo jlobal.net Phone (702) 786-0771 State CA Email nancy@aceco TStructionlv.com Hfconfirmation if APN 19-302-054 Type of Service Requested Comments Received By Date □ Cash Phone 213-448-5651 ZIP BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or project 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, ___________________________ DATE: 4-11-2025 . If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required 'f\ / Z «_ AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the above site addrafi^tareby authorize release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVlRONIgWO^^^XI TH DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. I inked FA ID Record Number Payment City Stockton Accepted By pe\6Q>\