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❑ 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 110 W. 10TH ST. City TRACY dAeLIFORNIA ZIP 95376 <br /> APN 235-054-05 9X4IJdXdUIN <br /> Type of Service ❑Application for ❑Consultation 30 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 ❑Facility Contact X Property Owner ❑Contractor ❑Architect <br /> required <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact xl Property Owner ❑Contractor ❑Architect <br /> First Name BRAVINLastname PHAN IfcontractpC,j,Rdiyate,Lv?+~OAcensenumber <br /> Address 1340 MANLEY DR city TRACY State ZIP 5 77 <br /> Phone Phone Email <br /> (209)637-1789 �4TRACYMILKTEA@(3MAIL.COM <br /> ❑Billing Party ❑Facility Owner ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and license number <br /> Address City State ZIP <br /> Phone Phone Email <br /> ❑Billing Party ❑Facility Owner, ❑Facility Contact ❑Property Owner ❑Contractor ❑Architect <br /> First Name Last name If contractor,indicate type and c�Ml�ryV <br /> Address City State ZIP <br /> Phone Phone Email <br /> ?015 <br /> sA <br /> BILLING ACKNOWLEDGEMENT:I,the undersigned property or business owner,operator or authorized agent of same,acknowledg 'G—W/W Ty <br /> specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business a's'i8 I Ik <br /> form. ENT <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 Ordinance Codes, <br /> Standards,STATE and FEDERAL laws. / 2/6/2025 <br /> APPLICANT'S SIGNATURE: rkVih DATE: <br /> �I PROPERTY/BUSINESS OWNER ❑OPERATOR/MANAGER ❑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 /> 2 32G 2 <br /> Date PE Fee Record Number <br /> ❑Cash ❑Check# Confirmation# ( ? Payment <br /> `��� T�U�/ Received By <br /> Rev 07/10/2024 <br /> l— <br />