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D New Facility IN Existing Facility <br />San Joaquin County Environmental Health Department <br />Application Form <br />Facility Name <br />Auntie Anne's Pretzel #CA121 <br />Site Address <br />3200 N Naglee Rd. #158 <br />City <br />Tracy <br />State <br />CA <br />ZIP <br />95304 <br />APN Supervisor District <br />Type of Service <br />Requested <br />0 Application for <br />Operating Permit <br />0 Consultation DI Change of Owner 0 Repairs or Remodel 0 Other <br />Comments New Ownership - Fresh Dining Concepts, LLC <br />If mobile food truck or <br />pumper truck <br />License Plate Number VIN <br />Contact Types <br />required <br />0 Billing Party ECI Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />0 Billing Party g Facility Owner 0 Facility Contact 0 Property Owner 0 Contractor 0 Architect <br />First Name <br />Fresh Dining Concepts, LLC <br />Last name If contractor, indicate type and license number <br />Address <br />1600 Ponce de Leon Blvd., Floor 10 <br />City <br />Coral Gables <br />State <br />FL <br />ZIP <br />33134 <br />Phone <br />786-369-0471 <br />Phone Email <br />billing@freshdiningconcepts.com <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 license lailien . <br />PC Ivi4 ZIP ElLO <br />JAN <br />Address City State <br />Phone Phone Email 24 20 SAN dr, , <br />6 ---,-,A •Lii <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 />10 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 altZ:14 I" . • 20( if <br />HEALTH DEPARTMENT hourly charges associated with this project or activity will be billed to me or my business as identi idle-404 v TA <br />'1% <br />this application and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes, <br />laws. <br />, la+ .0;11, idyl DATE: 01/16/2025 <br />OWNER 0 OPERATOR! MANAGER la0THER 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 />Gladys Downing, License Expert <br />Title Fresh Dining Concepts, LLC <br />at the above site address, hereby authorize the <br />JOAQUIN COUNTY ENVIRONMENTAL HEALTH <br />Accepted By,.. <br />es c-c) <br />Assigned To, <br />L.—N,.. k_c< ,e_ _S- <br />Linked FA ID <br />V-A- 05:4 3-1 OS" <br />Date PE Fee Record Number <br />f)R.5003303 <br />(i/S-2:2__ il Cl <br />Payment <br />0 Cash 0 Check # ,,Confirmation # i 41 Received By <br /> zyi_L <br />Rev 07/10/2024