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D New Facility Il Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Teatoxery <br />Site Address <br />917 N Central Ave <br />City <br />Tracy <br />State <br />CA <br />ZIP <br />95376 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation )14hange of Owner CI Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />Rocio <br />Last name <br />Adelantado <br />If contractor, indicate type and license number <br />Address <br />1445 Monterey Ct <br />City <br />Tracy <br />State <br />CA <br />ZIP <br />95376 <br />Phone <br />408-469-2560 <br />Phone <br />209-207-9839 <br />Email <br />teatoxerydirector@gn-ail.com <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />and liceRA47z A i <br />ZIP F?PCE/ <br />OC T <br />First Name Last name If contractor, indicate type <br />Address City State <br />Phone Phone Email f <br />U <br />n <br />I 2024 SAN . in A —. <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor rktiiikiWIWEtWri <br />''''PA R TiciA, <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <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 tha k to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />Standards, STATE and FEDERAL laws. <br />APPLICANT'S SIGNATURE: DATE: 10/08/24 <br />0 PROPERTY / BUSINESS OWNER 0 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />Title <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 address, hereby authorize the <br />release of any and all results, geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. <br />, Accepted By Assigned • To . . Linked FA ill <br />Oo 2-02- 1 <br />Date <br />c CI 2 _.../ PE <br />0002_ <br />Fee, t -9_ 2_ - Record Number (Z,2i--/0056/0 <br />0 Cash 0 Check # 7Confirmation # i9 b s 3 o \ i .._ <br />Payment <br />Received By <br />Rev 07/10/2024