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Docusign Envelope ID: DOA33DB2-40BF-464C-A317-518BFA314742 <br />0 New Facility n Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name TRADITIONS L LC . <br />Site Address 400 W 11TH ST City TRACY State CA ZIP 95376 <br />APN 235 -040 -11 Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />tAlct As e o <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />XE1 Billing Party :CI Facility Owner X0 Facility Contact X0 Property Owner 0 Contractor 0 Architect <br />XE Billing Party )CI Facility Owner E Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name VI J AYA MADHURI Last name KAKARLA If contractor, indicate type and license number <br />Address 2237 BENTLEY RIDGE DR City <br />SAN JOSE <br />State CA ZIP 95138 <br />Phone <br />408 -373 -3871 <br />Phone Email <br />madhurikakar1a7Oomai1.com <br />0 Billing Party 0 Facility Owner )47 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name SRIDHAR Last name KANCHETI If contractor, indicate type and license number <br />Address State 620 IRIS AVE CitY SUNNYVALE CA ZIP 94086 <br />Phone <br />669-467 -0072 <br />Phone Email <br />kancheti.sridhar@gmail.com <br />0 Billing Party 0 Facility Owner 0 Facility Contact X0 Property Owner 0 Contractor 0 Architect <br />First Name JOSH Last name ZACHARIAH If contractor, indicate type and license number <br />Address 7777 W BATES RD City TRACY <br />State CA ZIP 95304 <br />Phone <br />209 -732 -6617 <br />Phone Email <br />inshi7achariaha nail mom <br />BILLING ACKNOWLEDGEMENT: <br />specific ENVIRONMENTAL <br />form. <br />I also certify that I have prepared <br />Standards, STATE and FEDERAL <br />APPLICANT'S SIGNATURE: <br />X0 PROPERTY / BUSINESS <br />If APPLICANT is not the BILLING <br />AUTHORIZATION TO RELEASE <br />release of any and all results, <br />DEPARTMENT as soon as it <br />I, the undersigned property or business owner, operator or authorized agent of same, acknowledge that all siteAr project <br />HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as id ' pn this <br />44. <br />this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUN6) <br />I. laws. ....,9nedby, 11/7/2024 /le <br />. DATE: $4e) <br />- Tar m.ut td• <br />OWNER 52 8°ErtirEFIATOR / MANAGER 0 OTHER AUTHORIZED AGENT <br />PARTY, proof of authorization to sign is required <br />INFORMATION: When applicable, I, the owner or operator of the property located <br />geotechnical data and/or environmental/site assessment information to the SAN <br />is available and at the same time it is provided to me or my representative. <br />6:41 A , al <br />L-7 dad 2 202# <br />Title • /PA vi/i. WiV <br />—10•/..„ 04/4 Coo <br /> <br />0 F Afh, <br /> <br />at the above site address, he izMe <br /> <br />JOAQUIN COUNTY ENVIRONMENTAL Shjy <br />Accepted By <br />( <br />,, <br />c.A_zy i,te C-.19 <br />Assigned To <br />1.....kcs..,ne c <br />Linked FA ID <br />fil. COO 3(:). 3 <br />Date <br />1 i - 2:9' - 2e-4- <br />PE <br />( 47 0.2— <br />Fee n :2_7 <br />..........-- S ( -9-z • Record Number ...._ <br />S R2.4 (b(D(0.95 <br />El Cash 0 Check 4f ['Confirmation # 1 q 11 D1631-- Payment <br />Received By <br />Rev 07/10/2024