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❑ New Facility Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Ahmed's Sons Inc <br /> Site Address City State ZIP <br /> 1257 West Yosemite Avenue Manteca California 95337 <br /> APN Supervisor District <br /> 20015015 <br /> Type of Service ❑ Application for ❑ Consultation ❑ Change of Owner ❑ Repairs or Remodel 121 Other <br /> Requested Operating Permit <br /> Comments <br /> Remove existing dispenser and install new dispensers. <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> required <br /> ❑ Billing Party Facility Owner acility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, Indicate type and license number <br /> Asim Ahmed <br /> Address City State ZIP <br /> 1257 West Yosemite Avenue Manteca California 95337 <br /> Phone Phone Email <br /> 209- 23-1 24 chevron91848 mail.com <br /> Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner Contractor ❑ Architect <br /> P. <br /> First Name Last name If contr ,tor, indicate type and license number <br /> Nwesten, Inc. Class A 1073967 <br /> Address City State ZIP <br /> 2403 E. Belmont Avenue Fresno California 93701 <br /> Phone Phone Email <br /> 559-485-3456 hilli .1 man nwestco.com <br /> ❑ Billing Party ❑ Facility Owner ❑ Facility Contact ❑ Property Owner ❑ Contractor ❑ Architect <br /> First Name Last name If contractor, indicate type I is rl r <br /> Address City State ZIP <br /> Phone Phone Email SAN 02 <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, acknowledge s F]rAJe <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as iden i � T <br /> form. <br /> 1 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: DATE: 1/30/2025 <br /> ❑ PROPERTY/ BUSINESS OWNER ❑ OPERATOR/ MANAGER ❑O OTHER AUTHORIZED AGENT Contractor <br /> Title <br /> If APPLICANT is not the BILLING PARTY, proof of authorization to sign is required <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, 1, 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 � ^ Linked FA ID <br /> �llt-(ate 1, (N�Xn�O�J�r �i4 ObO��O <br /> Date al 25 PE 23 O� Fee / at) Record Number <br /> SRa50ms33 <br /> I I❑ Cash ❑ Checl<#J Confirmation 4 Payment <br /> C/{� 77 Received By <br /> Rev 07/10/2024 <br />