Laserfiche WebLink
❑ New Facility ❑ Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name <br /> Poppy El Dorado <br /> Site Address City State Zip <br /> 713 N El Dorado Stockton CA 95202 <br /> APN Supervisor District <br /> Type of Service ❑Application for ❑Consultation ffChangeofCwner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> o uo n W C kA n Cn exlsh')rlbits id] <br /> If mobile food truck or I License P e Number ViN <br /> pumper truck <br /> Contact Types 6A Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> (�Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Ashwin Pra sad <br /> Address city State ZIP <br /> 1320 Decoto Rd, Suite 200 Union City CA 94587 <br /> Phone Phone Email <br /> 510-270-3483 510-270-3437 ashwin@loopneig borhood.com <br /> ❑Billing Party Q Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,Indicate type and license number <br /> Varish Go al (Poppy Markets LLC <br /> Address City State ZIP <br /> 1320 Decoto Rd suite 200 Union City CA 94587 <br /> Phone Phone Email <br /> 510-270-3483 ashwin@loopneig borhood.com <br /> ❑Billing Party ❑Facility Owner WiFacility Contact ❑Property Owner Cl Contractor ❑Architect <br /> First N a Last name If contractor,indicate type and license number <br /> aTohn Ellis <br /> Address City State ZIP <br /> 1320 Decoto Rd, Suite 200 Union City CA 94587 <br /> Phone Phone Email <br /> 5106005434 'ohn loo nei borhood.com <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 applicat2�7- <br /> work to be performed will be done in accordance with all SAN IOAQUIN COUNTY Ordinan 04k <br /> Standards,STATE and FEDERAL laws. II f <br /> APPLICANT'S SIGNATURE: • DATE: � J�7;r ��+ VE <br /> ❑PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑OTHER AUTHORIZED AGENT DES 0 r <br /> Title C 2025 <br /> If APPLICANT is not the$ILLING 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,hereto <br /> release of any and all results,geotechnical data and/or environmental/site assessment information to the SAN JOAQUIN COUNTY ENVIRONI D H�E ]Y <br /> DEPARTMENT as soon as it Is available and at the same time it is provided to me or my representative. <br /> AL <br /> Accepted By - e Assigned To j cA f i Linked FA ID )u J 6�r 1 <br /> d '&A CS CJ ! I�pjr [ 0 <br /> Date' �_ � er <br /> PE I � �.y 2 Fee �.� U`� !��• Re rd N m <br /> , V ( lY <br /> �,/ r, Payment <br /> ❑Cash ❑Check q n/COnfirmatl0l 1 � 2 Received By <br /> Rev 07/10/2024 i <br />