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❑ New Facility ❑ Existing Facility <br /> (needs SR#) <br /> San ,baquin County Environmental Health Department <br /> Appl i cation Form <br /> Fad Iity Name <br /> Fast and Easy Mart#103 <br /> Ste Address City Sate ZIP <br /> 8660 Lower Sacramento Rd Stockton CA 95210 <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation ❑Change of Owner 9 Fepairsor Femodel ❑Other <br /> Flaquested Operating Permit <br /> Comments <br /> Tank 1 Veeder Root 409 Replacement,Tank 1 Veeder Root PLLD Replacement <br /> If mobile food truck or License Rate Number VAN <br /> pumper truck <br /> Contact Types Rl Billing Party ❑Facility Owner ®Facility Contact ❑Property Owner ®Contractor ® Requestor <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Ronnie Lewis Last name If contractor,indicate type and license number <br /> A-B-D40-C38-C10-C20 <br /> Address City Sate ZIP <br /> 4901 Warehouse Way Sacramento CA <br /> 9582E <br /> Phone Phone Email <br /> 916-993-6312 service@iecservices.com <br /> ❑Billing Party ❑Fad Iity Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City Sate ZIP <br /> Phone Phone Email <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 Elate ZJP <br /> Phone Phone Email <br /> BI W NGAG<NOWLEDGRA BVM 1,the undersigned property or businessowner,operator or authorized agent of same,acknowledge that all site and/or project <br /> specific ENVIRONMENTAL HEALTH DEPARTMBVT 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 acxordance with all SAN JOAQUIN COUNTYOrdinance Codes, <br /> aandards,SFATEand FBDERALlaws. �� 6/10/2026 <br /> APPLJ CANT SSGNATURE DATE <br /> ❑PROPERTY/BUSNESSOWNER ❑OPERATOR/MANAGER ®OTHERAUTHOFdZEDAGENT Contractor <br /> Title <br /> If APPLICANT is not the BI W NG PAR Y,proof of authorization to sign is required <br /> AUTHORIZATION TO RHEAS=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 COUNTYBWAIONMBVTALHEALTH <br /> DEPARFMBVrassoon as it isavailable and at the same time it is provided to me or my representative. <br /> Accepted By Assigned To Linked FA ID <br /> Date PE Fee Fecord Number <br /> ❑Cash ❑(heck# ❑Confirmation# PaymentPeceived By <br /> Rev 07/10/2024 2 of 6 <br />