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New Facility □ Existing Facility <br />Facility Name SKY MINI MART <br />Site Address State ZIPCA 95206 <br />APN <br />□ Consultation □ Change of Owner □ Repairs or Remodel □ Other <br />License Plate Number VIN <br />□ Billing Party □ Facility Owner □ Facility Contact □ Property Owner □ Contractor □ Architect <br />H Billing Party □ Facility Owner 0 Facility Contact □ Contractor □ Architect <br />First Name Last name If contractor, indicate type and license numberJALALNAGI <br />Address City ZIP163 FRENCH CAMP TPKE STOCKTON 95206 <br />Phone <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 □ 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 />0 - zz-/- 2-S'DATE: <br />□ PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER □ OTHER AUTHORIZED AGENT <br />Title <br />Accepted By Assigned To Linked FA ID <br />itooa <br />□ Cash □ Check # <br />Rev 07/10/2024 <br />Contact Types <br />required <br />If mobile food truck or <br />pumper truck <br />0 Application for <br />Operating Permit <br />Email <br />bookkeepingplustax@gr iail.com <br />San Joaquin County Environmental Health Department <br /> Application Form <br />Phone <br />(209)818-3124 <br />I Type of Service <br />Requested <br />Comments <br />□ Property Owner <br />Vidal ?■ <br />PE <br />163 FRENCH CAMP TPKE <br />Supervisor District <br />4m.- <br />H’Confirmation # <br />Date^.qa4- ao <br />Rockton <br />FA00QI1733 <br />__ Record Number <br />3^50)1513 <br />Received By <br />S- <br />Fee4m <br />State CA <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 O^gtiiii.Codes <br />Standards, STATE and FEDERAL laws. / <br />APPLICANT'S SIGNATURE: DATE: 0 ‘1 Z^/~ <br />..... -------- <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 addr^L^Q^Q/yjthorize the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative, ’H Q <br />’4 —