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0 New Facility 'Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name T4 TRACY TEA FOR, INC. <br />Site Address <br />11 0 W. 10TH ST. City TRACY 64LIFORNIA ZIP 95376 <br />APN 235-054-05 guAhvijarduiN <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation )0 Change of Owner 0 Repairs or Remodel 0 Other <br />Comments <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />0 Billing Party 0 Facility Owner 0 Facility Contact )10 Property Owner 0 Contractor 0 Architect <br />0 Billing Party 0 Facility Owner 0 Facility Contact )1:1 Property Owner 0 Contractor 0 Architect <br />First Name <br />BRAVIN <br />, <br />Last name pHAN If contractidAtedwdAcense number <br />Address 1340 MANLEY DR City <br />TRACY <br />State zIP95377 <br />Phone <br />(209)637-1789 <br />Phone <br />-4TRACYMILKTEA@GMAILCOM <br />Email <br />0 Billing Party 0 Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name If contractor, indicate type and license number <br />Address City State ZIP <br />Phone Phone Email <br />0 Billing Party 0 Facility Owner. 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name Last name If contractor, indicate type and <br />fi'iv r C- Address City State ZIP j itir) <br />4...r FEB <br />Phone Phone Email 0 7 20x <br />SAN 4../ o <br />'1 <br />J A <br />F QUi <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 />X 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, acknowledgeltiatAt y atuvie ..,_ <br /> <br />HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as i AFINIR 1,1i1.. <br />lv/Elvr <br />this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />laws. 2/6/2025 bt -Alein. pi. DATE: <br />OWNER 0 OPERATOR/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 />Title <br />at the above site address, hereby authorize the <br />JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />Accepted By Assigned To Linked FA ID <br />Date PE Fee <br />1 -9-2 --- <br />Record Number <br />8251108L\a) <br />0 Cash 0 Check # <br />, <br />Confirmation # <br />Payment <br />Received By <br /> aiLy..... <br />Rev 07/10/2024 <br />4