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f ft. San Joaquin County Environmental Health Department Application Form Facility Name H&M Petroleum, Corp. ZIPStateCitySite Address CA 95304Tracy3788 N. Tracy Blvd. Supervisor District □ Repairs or Remodel □ Other□ Change of Owner□ Consultation VINLicense Plate Number □ Contractor SJ Architect□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party ® Architect□ Contractor□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party If contractor, indicate type and license numberLast nameFirst Name BaumanJoshua ZIPStateAddress 953564335-B Northstar Ave CA Phone @apiarc.com □ Architect□ ContractorEl Property Owner□ Facility ContactS Billing Party E) Facility Owner If contractor, indicate type and license numberLast nameFirst Name 3788 Tracy, LLC. ZIPCityAddress 94550Livermore @gmail.com □ Contractor □ Architect□ Property Owner□ Facility Contact□ Facility Owner□ Billing Party Last nameFirst Name ZIPStateCityAddress EmailPhonePhone mi DATE: S OTHER AUTHORIZED AGENTOPERATOR/MANAGER□ PROPERTY / BUSINESS OWNER Unked FA ID PE 1^0/CUD 17^32332^ If mobile food truck or pumper truck Contact Types required IX) Application for Operating Permit 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 DEPARTMENTas soon as it is available and at the same time it is provided to me or my representative. Date Phone 209-577-4661 Phone 925-819-2340 Type of Service Requested Comments 2216 Pyramid Street Phone Email joshua Email haminil 0 Assigned To - City Modesto Reco,JNunibe,Ap^^7 Accepted By State CA APN 212-25-002 If contractor, indicate type and license number _________________________________________________ _____________________________ BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business aST'&q?ifjedbh)ftiJV7^L forrn- A A I also certify that I have prepared this applicZiMlant/t/fSlthe work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, ‘-'V T Standards, STATE and FEDERAL laws. I I f|/IkAC./f)“71 /J APPLICANT'S SIGNATURE: / /^(7» ________________________ DATE: 1 ------------------ Designer Title