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E-MAILED <br /> El New Facility ® Existing Facility <br /> San Joaquin County Environmental Health Department <br /> Application Form <br /> Facility Name — -- <br /> China Wok Express <br /> Site Address 15020 5 Harlan RD City Lathrop State CA ZIP 95330 <br /> APN Supervisor District <br /> Type of Service ❑Application for 0 Consultation lid Change of Owner ❑Repairs or Remodel ❑Other <br /> Requested Operating Permit <br /> Comments <br /> If mobile food truck or License Plate Number VIN <br /> pumper truck <br /> Contact Types ❑Billing Party ❑Facility Owner 0 Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> required <br /> �f Billing Party tR Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,Indicate type and license number <br /> Yu Xing Lin <br /> Address 15020S Harlan RD C't' Lathrop State CA ZIP 95330 <br /> Phone 0 Phone Email yufin111368@ mail.com51 <br /> ❑Billing Party ❑Facility Owner Iia Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,Indicate type and license number <br /> Caichan Liang <br /> Address 15020 5 Harlan RD City Lathrop State CA ZIP 95330 <br /> Phone Phone Email <br /> 510-206-6007 )oyceliangS 51 @gmail.com <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type number <br /> Address City State C�I <br /> /V <br /> Phone Phone Email CT 4 <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowled to/a, ra ect <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me orpipes <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 Oes, <br /> Standards,STATE and FEDERAL laws. Caichan Liang DATE: 10/22/202 <br /> APPLICANT'S SIGNATURE: <br /> ❑PROPERTY/BUSINESS OWNER %I OPERATOR/MANAGER Q OTHER AUTHORIZED AGENT <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 By Assigned To Linked FA ID <br /> L� rbc �A o0 20 bb <br /> Fee pt Record Number <br /> ;ate 23'�5 PE ��40 Z �� 1 Clio 1)Pim I I <br /> '— <br /> Payment <br /> ❑Gash ❑Check a Confirmation q 2��S 2y 3 5 Received By <br /> Rev 07/10/2024 <br /> S <br />