COMPLIANCE INFO_2024 - Laserfiche WebLink

Home Browse Search

(3 R -2_oaco ID New Facility 0 Existing Facility San Joaquin County Environmental Health Department Application Form iNQ Facility Name Saltyy's Cakes Site Address 14222 W Byron Rd City Tracy State CA ZIP 95304 APN Supervisor District Type of Service Requested Id Application for Operating Permit 0 Consultation 0 Change of Owner 0 Repairs or Remodel 0 Other Comments If mobile food truck or pumper truck License Plate Number VIN Contact Types required 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect 12 Billing Party 0 Facility Owner 21 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name Gursimran Last name Singh If contractor, indicate type and license number Address 14222 W Byron Rd City Tracy State CA ZIP 95304 Phone (209) 321-2113 Phone 2098009577 Email thesaltedcafe@gmailicom 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email 0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect First Name Last name If contractor, indicate type and license number Address City State ZIP Phone Phone Email 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, Standards, STATE and FEDERAL laws. APPLICANT'S SIGNATURE: DATE: 10/8/24 PROPERTY / BUSINESS OWNER 12 OPERATOR / MANAGER 0 OTHER AUTHORIZED AGENT Owner Title 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 DEPARTMENT as soon as it is available and at the same time it is provided to me or my representative. Accepted By Assigned To Linked FA ID Date \O•c6-2- PE Fee ecord Number 2_ LA 0 1 6 . Cash 0 Check # 0 Confirmation # 1 Payment Received By LR1 Rev 07/10/2024 v\I\ cke Qle