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❑ New Facility X Existing Facility <br /> Nyecfs S # <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Tokay Kwik Sery <br /> Site Address City State ZIP <br /> 420 W. Kettleman Lane Lodi CA 95240 <br /> APN Supervisor District <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner epairs or Remodel ❑ Other <br /> Requested Operating Permit <br /> Comments <br /> see application for scope of work <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner 8 Contractor ❑ Architect <br /> required <br /> Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner Contractor ❑ Architect <br /> �2e ices <br /> First Name Last name If contractor, indicate type and license number <br /> Cindy Cadacio-Chan 958763 A <br /> Address City State ZIP <br /> P.O. Box 1394 Lafayette CA 94549 <br /> Phone Phone Email <br /> 925-499-6294 permits@ecochek.com <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 ❑ A ��� <br /> First Name Last name If contractor, indicate type ancFI1&4&WVei1 <br /> Address City State ZI Lli)v <br /> 025 <br /> Phone Phone Email H RONM <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner, operator or authorized agent of same, acknowledge that all site and/or p Nr <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 Ordinance Codes, <br /> Standards, STATE and FEDERAL laws <br /> APPLICANT'S SIGNATURE: 7� DATE: 9/912024 <br /> ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER MOTHER AUTHORIZED AGENT Offlce/BuslnessAffairs Manager <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 Byl.-� � Assigned To � � Linked FA ID <br /> v Q nI <br /> Date/ ^ � PE� Fee /Y �3� �e Record Number 511250 485 <br /> ❑ Cash ❑ Check# Confirmation# /�Q?'7'7t� Payment <br /> 26 p ( Received By <br /> Rev 07/10/2024 <br />